Coast Plaza Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36206 Based on interview and record review the facility failed to provide an appropriate transfer for five (5) of 20 sampled patients (Patient 2, 8, 9, 14, and 15). For Patients 2, 14, and 15, there was no evidence that the facility completed the required “EMTALA Patient Transfer Form,” which indicated reason for transfer, disposition, name of accepting physician and accepting facility, mode of transportation, data or records being sent to the accepting facility and physician certification of patients condition, and of explaining the specific risk and benefits of the transfer. Patient 8 and 9’s “EMTALA Patient Transfer Form,” was incomplete. The physician certification did not indicate Patient 8’s and Patient 9’s condition (stable or unstable) and the risk and benefits of transfer were not specified on the form. In addition, Patient 9’s mode of transportation was not documented. This deficient practice had the potential to result in delay or duplicate treatment when the transferring hospital (Hospital A) did not provide all the necessary patient information to receiving hospitals upon transferring Patients 2, 8, 9, 14, and 15. (Refer to C-2409) Findings: During an observation and interview in the Emergency Department (ED, a hospital facility providing 24 hour, 7 days a week immediate, unscheduled care for severe injuries or illnesses) on 12/22/2025 at 10:04 a.m. with Triage Registered Nurse (TRN), TRN stated when transferring a patient to another hospital/receiving facility, the physician needed to communicate with another physician at the receiving facility. The Patient must be accepted by the accepting physician. The physician needed to state whether or not the patient was stable for transfer and needed to certify that he/she (referring physician) had explained the risk and benefits of the transfer to the patient. Both the referring physician and the patient or legally responsible party (LRP) needed to sign in acknowledgment of the condition of the patient upon transfer and that the risk and benefits had been explained to the patient. TRN presented a blank document titled, “EMTALA Patient Transfer Form.” TRN stated the EMTALA Patient Transfer Form should be filled out in its entirety. The Form included, but not limited to, documentation for Reason for Transfer, Disposition (name of accepting physician, name of accepting facility, mode of transportation), data being sent to the receiving facility, vital signs, patient condition, Physician Certification, Transfer Risk and Transfer Benefits, and signature of referring physician and the patient being transferred. Patient medical records are sent to the receiving facility. TRN stated that the physician would decide the mode of transportation, whether via Emergency Medical Services (EMS, basic transport for stable patients) ambulance or paramedics (for critical or unstable patients). Vitals signs are also needed to be documented on the form. The Form should be completely filled out to ensure all the elements of an appropriate and safe transfer had been met. During a review of Patient 2’s “Emergency Department Triage,” dated 8/25/2025 at 11:57 a.m., the Emergency Department Triage document indicated the following: Patient 2 arrived at the Emergency Department (ED) via ambulance for general weakness. Patient 2 also complained of cough. Patient 2 stated “I’m hungry.” During a review of Patient 2 ‘s “Emergency Department Note,” dated 8/25/2025 at 7:40 p.m., the Emergency Department Note indicated the following: Care start time: 8/25/2025 at 12:02: Patient 2 was brought by Emergency Medical Services (EMS) ambulance for feeling weakness and being hungry. Patient 2 had been lethargic and nonverbal upon arrival. Patient 2 was given Narcan (a life-saving medication that reverses an opioid overdose) “to try and wake him up ...patient (Patient 2) appears to be under the influence of drugs ...patient (Patient 2) was signed out to me (MD 2) by (MD 1). At 2:30 p.m., patient (Patient 2) was reassessed, now awake, alert, oriented and asking for food ...patient (Patient 2) was given normal saline (a sterile mixture of salt and water), azithromycin (an antibiotic) and ceftriaxone (an antibiotic) ...Disposition: patient (Patient 2) requires admission and ongoing acute care as patient (Patient 2) is at risk for decompensation ... patient (Patient 2) will be admitted for further therapy, hemodynamic monitoring and careful hydration ...Accepting Care Team: Current data and ongoing care discussed with accepting physician (AMD 1). Patient (Patient 2) accepted at 7 p.m. Patient (Patient 2) to be dispositioned to: Receiving Hospital (Hospital B). Diagnosis included: Pneumonia (lung infection), Hyponatremia (low salt level in the blood), Anemia (low red blood cells) and Meth (methamphetamine, lab-made stimulant with high addiction potential) use. During a review of Patient 2’s “Ambulatory Assessment,” dated 8/25/2025 at 9:30 p.m., the Ambulatory Assessment indicated the following: Disposition: Transferred ...Patient 2 transferred to ambulance gurney for transfer to Hospital B. During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with the Clinical Analyst Registered Nurse (CARN) 1, CARN 1 stated the following: Patient 2 was transferred to Hospital B. CARN 1 verified that an EMTALA patient transfer form had not been found in Patient 2’s medical record. The transfer form should have been completely filled, including the reason for transfer, physician certification of Patient 2’s condition and that the risk and benefits had been explained to Patient 2, signatures of both the referring physician and Patient 2, in acknowledgement of the explanation of reason for transfer and risk and benefits have been explained. In addition, the vital signs and mode of transportation should be documented to ensure a safe transfer, along with documentation of the documents or medical records sent with Patient 2 to Hospital B. CARN 1 stated she (CARN 1) did not know why Patient 2 was being transferred, possibly for insurance reasons. During a review of Patient 8’s “Emergency Department Triage,” dated 8/24/2025 at 12:17 p.m., the Emergency Department Triage record indicated the following: Patient 8 arrived at the Emergency Department (ED) from home, accompanied by parents. Patient 8 complained of flu-like symptoms, cough, sore throat, and shortness of breath. During a review of Patient 8 ‘s “Emergency Department Note,” dated 8/24/ 2025 at 12:10 p.m., the Emergency Department Note indicated the following: “10-year-old ...brought in by mother ambulatory ...with complaint of coughing, shortness of breath, sore throat since last night ...” Medical Decision Making: Patient 8 was given Rocephin (an antibiotic used to treat bacterial infections and. Zithromax (an antibiotic to treat a wide range of bacterial infections). Patient 8 was also given Solu-Medrol (an injectable corticosteroid used to treat severe inflammation), Xopenex (a short-acting bronchodilator [rescue medication] to treat sudden airway tightening) handheld nebulizer breathing treatment, and oxygen increased to 4 Liters (L) via facemask. Diagnosis: acute Bronchopneumonia (a lung infection causing inflammation in patches in the long and nearby tissue), hypoxemia (low oxygen levels in the blood), and dyspnea (shortness of breath). During a review of Patient 8’s “Ambulatory Assessment,” dated 8/24/2025 at 10:02 p.m., the Ambulatory Assessment indicated the following: At 8:25 p.m. “Gave transfer patient report to RN.” Accepting facility was Hospital C. Disposition: Transferred on 8/24/2025 at 9:33 p.m., to acute care hospital. During a review of Patient 8’s “EMTALA Patient Transfer Form,” dated 8/24/2025, the EMTALA Patient Transfer Form indicated Patient 8 was being transferred. The name of the receiving facility was not documented, instead, the name of facility was documented as “Long Beach,” the name of a city. In addition, Patient 2’s condition was blank, not documented. The Section titled, “Physician Certification - Transfer Acknowledgement & Consent,” was blank. It did not indicate whether Patient 8’s emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and the parent for Patient 8, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there...) of the transfer were not specified or marked on the document. During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, Patient 8’s EMTALA Patient Transfer Form, was reviewed. CARN 1 stated that the form was incomplete. CARN 1 stated Patient 8 was transferred to another facility because Patient 8 was a pediatric (ages birth to 18 - 21 years old) patient. Patient 8’s condition upon transfer was not documented. The form was signed by the physician and the Patient 8’s parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 8’s emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 8. CARN 1 stated she did not know Patient 8’s condition upon transfer. CARN 1 also acknowledged that the name of the receiving facility was not documented on the form. During a review of Patient 9’s “Emergency Department Triage,” dated 8/24/2025 at 12:10 p.m., the Emergency Department Triage record indicated the following: Patient 9 arrived at the Emergency Department (ED) from home accompanied by a parent (s). Per parents, Patient 9 complained of vomiting and diarrhea since the day prior (8/23/2025). During a review of Patient 9 ‘s “Emergency Department Note,” dated 8/24/2025 at 12:10 p.m., the Emergency Department Note indicated the following: “2-year-old ...brought by parents with complaint of nausea, vomiting, diarrhea since last night ...Medical decision making: Result the work up reviewed case, discussed with accepting physician (AMD 2), pediatrician, at Hospital C, who accepts patient (Patient 9) for transfer ...Diagnosis: Acute Gastroenteritis (inflammation of the stomach or intestines, often call “stomach flu”) and dehydration (the body does not have enough water or fluid to function properly).” During a review of Patient 9’s “EMTALA Patient Transfer Form,” dated 8/24/2025 at 3:30p.m., the EMTALA Patient Transfer Form indicated Patient 9 was being transferred due to Patient 9 being a pediatric patient. The name of the receiving facility was not documented instead, the name of facility was documented as “Long Beach,” the name of a city. The Section titled, “Physician Certification - Transfer Acknowledgement & Consent,” was blank. It did not indicate whether Patient 9’s emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and Patient 9’s parent, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there ...) of the transfer were not specified or marked on the document. During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, CARN 1 stated the following: Patient 9 was transferred to another hospital because Patient 9 was a pediatric patient. CARN 1 verified that Patient 9’s EMTALA Patient Transfer Form was incomplete. The name of the receiving facility was not documented, only the name of the city (Long Beach) in which the hospital was located was documented. The form did not indicate the mode of transportation (ambulance or paramedics). The form was signed by the physician and Patient 9’s parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 9’s emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 9. CARN 1 stated it was very important to document the patients’ condition and mode of transportation upon transfer to ensure safe and appropriate transfer. During a review of Patient 14’s “Emergency Department Triage,” dated 7/25/2025 at 2:11 p.m., the Emergency Department Triage record indicated the following: Patient 14 arrived by ambulance from a skilled nursing facility to Emergency Department (ED) with a chief complaint for aggressive behavior and being assaultive towards staff. Patient 14 needed to be medically clear and then transferred to another hospital (receiving facility, Hospital D). During a review of Patient 14’s “Emergency Department Note,” dated 7/25/2025 at 2:14 p.m., the Emergency Department Note indicated the following: Patient 14 was from a nursing home with complaints of bizarre behavior and aggressive behavior toward staff. Patient 14’s Neurological assessment was alert and oriented to person, place, and time. Patient 14 was diagnosed with Psychotic behavior (involves a loss of contact with reality, characterized by distorted thinking, perceptions, and behaviors, primarily seen through hallucinations [seeing/hearing things not there] and delusions [false, fixed beliefs]) and was medically cleared to go to psychiatric hospital. During a review of Patient 14’s “Progress Notes Report,” dated 7/25/2025 at 9:03 p.m., the Progress Notes Report indicated the following: Patient 14 was transferred by ambulance. During an interview on 12/23/2025 at 10:26 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no “Transfer form” documentation in the medical chart for Patient 14. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to patient. There was no documentation of accepting representatives at the accepting facility. During a review of Patient 15’s “Emergency Department Triage,” dated 7/24/2025 at 11:19 p.m., the Emergency Department Triage record indicated the following: Patient 15 arrived in the Emergency Department (ED) accompanied by Deputy with a chief complaint of suicidal ideation (thoughts of considering death) and on a 5150 hold (a legal provision allowing police or mental health professionals to involuntarily detain someone for up to 72 hours for a psychiatric evaluation if they’re deemed a danger to themselves or others, or are gravely disabled due to a mental health crisis, enabling stabilization and assessment before potential release or further involuntary holds). During a review of Patient 15’s “Emergency Department Note,” dated 7/24/2025 at 11:19 p.m., the Emergency Department Note indicated the following: Patient 15 was a minor and got into verbal altercation at home and had thoughts of hurting self. Patient 15 was on a 5150 hold. Patient 15 needed to be transferred to Behavioral Health Unit (a specialized, secure hospital unit or facility designed to provide 24/7 care, stabilization, and treatment for individuals experiencing acute mental health crises, severe psychiatric disorders, or substance abuse issues) for evaluation. During a review of Patient 15’s “Progress Notes Report,” dated 7/25/2025 at 4:09 p.m., the Progress Notes Report indicated the following: Patient 15 was transferred to another facility (receiving facility, Hospital E). During an interview on 12/23/2025 at 10:36 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no “Transfer form” documentation in the medical chart for Patient 15. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to the patient. No documentation regarding accepting representatives at the accepting facility. During a review of the facility’s policy and procedure (P&P) titled, “EMTALA Guidelines for Emergency Department,” dated 8/2022, the P&P indicated the following: Transfer For Care Outside the Hospital: a. Unable Patients: An individual with an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain ...] such as the absence of immediate medical attention could reasonably be expected to result in: ...Placing the health of an individual in serious jeopardy; serious impairment of bodily functions; serious dysfunction of any bodily organ or part) which has not been stabilized may only be transferred for medical reasons or if the individual makes an informed request for transfer ...2. For Medical Reasons With Physician Certification: If the physician certifies in wring on the “Transfer Summary Form,” that, based on the reasonable risk and benefits to the patient, and based upon the information available at the time of the patient’s transfer, the medical benefits reasonably expected for the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient and, if pregnant, the patient’s unborn child from effecting the transfer. b. Stable Patients: Individuals who have an EMC which has been stabilized, i.e., who is Stable for Transfer, may be transferred to another facility for definite care under one of the following: ...Recommend Transfer For Medical Reasons: If a physician recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer, the transfer may then occur if the individual or legally responsible person (LRP) consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risk and benefits of the transfer on the “Transfer Summary Form.” Patient Transfer: It is the responsibility of the physician to ensure that all transfers for immediate care of an individual to another care facility will be carried out in accordance with the following: 1. Medical Treatment: The hospital will provide, within its capacity, medical treatment that minimizes the risk of transfer/referral to the individual’s health ... 2. Informed Consent: Where the transfer is medically recommended, the hospital will notify the individual or, where applicable, the individual’s LRP, both orally and in writing of the recommend transfer and reasons therefore ... 3. Informed Request: Where the transfer is in response to a request for the transfer by the individual, such request must be documented on the “Transfer Summary Form” and signed by the individual or the LRP ... a. For non-medical transfer, the “Transfer Summary Form,” must include a declaration by the physician that the individual is Stable for Transfer, and an acknowledgement by the individual or LRP that he/she has been offered continuing care at the facility, as well as the risk of the transfer and the reasons for the transfer. b. For transfers of individuals who have not been stabilized, the individual must acknowledge on the “Transfer Summary Form,” the risk of the transfer, his/her right to recommended treatment at the facility and the reasons for the requested transfer. 4. Contact Receiving Facility. A representative of the receiving facility must have confirmed that: a. The receiving facility has available space and qualified personnel to treat the individual; and b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment. 5. Copies of Medical Records/Consents/Certification, the Hospital will send the receiving facility copies of all pertinent medical records available at transfer, including: a. History b. Records related to the individual’s emergency medical condition. c. Observations of signs and symptoms; d. Preliminary diagnosis; e. Results of diagnostic studies or telephone reports of the studies; f. Treatment provided; g. Results of any tests; and h. A copy of the informed written request or certification and consent to transfer. 6. Transport By - Qualified Personnel: The transfer will be effected through qualified personnel and transportation equipment, as determined by the physician included the use of necessary and medically appropriate life support measures during the transfer ... 7. Complete Transfer Summary: The ED Physician shall ensure that a completed “Transfer Summary Form,” signed by the patient or legally responsible adult ... During a review of the facility’s policy and procedure (P&P) titled, “Higher Level of Care Transfers,” dated 11/2025, the P&P indicated the following: Under the direction of the Emergency Department (ED) Physician, Patients, requiring higher level of service will be appropriately transferred from the Emergency Department ...Higher level of care is defined as a level of care which cannot be provided at the Hospital. Procedure: Emergency Department Physician advises and documents need for transfer to higher level of care ...Once a facility accepts the patient, ED physician and ED clerk are informed by the charge registered nurse. As appropriate, patient / family members are advised of transfer. Arrangements are made for transportation. All appropriate documentation is on the E.D. (Emergency Department) Summary, Nurses’ Progress Notes and EMTALA Patient Transfer Form.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36206 Based on interview and record review the facility failed to provide an appropriate transfer for five (5) of 20 sampled patients (Patient 2, 8, 9, 14, and 15). For Patients 2, 14, and 15, there was no evidence that the facility completed the required “EMTALA Patient Transfer Form,” which indicated reason for transfer, disposition, name of accepting physician and accepting facility, mode of transportation, data or records being sent to the accepting facility and physician certification of patients condition, and of explaining the specific risk and benefits of the transfer. Patient 8 and 9’s “EMTALA Patient Transfer Form,” was incomplete. The physician certification did not indicate Patient 8’s and Patient 9’s condition (stable or unstable) and the risk and benefits of transfer were not specified on the form. In addition, Patient 9’s mode of transportation was not documented. This deficient practice had the potential to result in delay or duplicate treatment when the transferring hospital (Hospital A) did not provide all the necessary patient information to receiving hospitals upon transferring Patients 2, 8, 9, 14, and 15. Findings: During an observation and interview in the Emergency Department (ED, a hospital facility providing 24 hour, 7 days a week immediate, unscheduled care for severe injuries or illnesses) on 12/22/2025 at 10:04 a.m. with Triage Registered Nurse (TRN), TRN stated when transferring a patient to another hospital/receiving facility, the physician needed to communicate with another physician at the receiving facility. The Patient must be accepted by the accepting physician. The physician needed to state whether or not the patient was stable for transfer and needed to certify that he/she (referring physician) had explained the risk and benefits of the transfer to the patient. Both the referring physician and the patient or legally responsible party (LRP) needed to sign in acknowledgment of the condition of the patient upon transfer and that the risk and benefits had been explained to the patient. TRN presented a blank document titled, “EMTALA Patient Transfer Form.” TRN stated the EMTALA Patient Transfer Form should be filled out in its entirety. The Form included, but not limited to, documentation for Reason for Transfer, Disposition (name of accepting physician, name of accepting facility, mode of transportation), data being sent to the receiving facility, vital signs, patient condition, Physician Certification, Transfer Risk and Transfer Benefits, and signature of referring physician and the patient being transferred. Patient medical records are sent to the receiving facility. TRN stated that the physician would decide the mode of transportation, whether via Emergency Medical Services (EMS, basic transport for stable patients) ambulance or paramedics (for critical or unstable patients). Vitals signs are also needed to be documented on the form. The Form should be completely filled out to ensure all the elements of an appropriate and safe transfer had been met. During a review of Patient 2’s “Emergency Department Triage,” dated 8/25/2025 at 11:57 a.m., the Emergency Department Triage document indicated the following: Patient 2 arrived at the Emergency Department (ED) via ambulance for general weakness. Patient 2 also complained of cough. Patient 2 stated “I’m hungry.” During a review of Patient 2 ‘s “Emergency Department Note,” dated 8/25/2025 at 7:40 p.m., the Emergency Department Note indicated the following: Care start time: 8/25/2025 at 12:02: Patient 2 was brought by Emergency Medical Services (EMS) ambulance for feeling weakness and being hungry. Patient 2 had been lethargic and nonverbal upon arrival. Patient 2 was given Narcan (a life-saving medication that reverses an opioid overdose) “to try and wake him up ...patient (Patient 2) appears to be under the influence of drugs ...patient (Patient 2) was signed out to me (MD 2) by (MD 1). At 2:30 p.m., patient (Patient 2) was reassessed, now awake, alert, oriented and asking for food ...patient (Patient 2) was given normal saline (a sterile mixture of salt and water), azithromycin (an antibiotic) and ceftriaxone (an antibiotic) ...Disposition: patient (Patient 2) requires admission and ongoing acute care as patient (Patient 2) is at risk for decompensation ... patient (Patient 2) will be admitted for further therapy, hemodynamic monitoring and careful hydration ...Accepting Care Team: Current data and ongoing care discussed with accepting physician (AMD 1). Patient (Patient 2) accepted at 7 p.m. Patient (Patient 2) to be dispositioned to: Receiving Hospital (Hospital B). Diagnosis included: Pneumonia (lung infection), Hyponatremia (low salt level in the blood), Anemia (low red blood cells) and Meth (methamphetamine, lab-made stimulant with high addiction potential) use. During a review of Patient 2’s “Ambulatory Assessment,” dated 8/25/2025 at 9:30 p.m., the Ambulatory Assessment indicated the following: Disposition: Transferred ...Patient 2 transferred to ambulance gurney for transfer to Hospital B. During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with the Clinical Analyst Registered Nurse (CARN) 1, CARN 1 stated the following: Patient 2 was transferred to Hospital B. CARN 1 verified that an EMTALA patient transfer form had not been found in Patient 2’s medical record. The transfer form should have been completely filled, including the reason for transfer, physician certification of Patient 2’s condition and that the risk and benefits had been explained to Patient 2, signatures of both the referring physician and Patient 2, in acknowledgement of the explanation of reason for transfer and risk and benefits have been explained. In addition, the vital signs and mode of transportation should be documented to ensure a safe transfer, along with documentation of the documents or medical records sent with Patient 2 to Hospital B. CARN 1 stated she (CARN 1) did not know why Patient 2 was being transferred, possibly for insurance reasons. During a review of Patient 8’s “Emergency Department Triage,” dated 8/24/2025 at 12:17 p.m., the Emergency Department Triage record indicated the following: Patient 8 arrived at the Emergency Department (ED) from home, accompanied by parents. Patient 8 complained of flu-like symptoms, cough, sore throat, and shortness of breath. During a review of Patient 8 ‘s “Emergency Department Note,” dated 8/24/ 2025 at 12:10 p.m., the Emergency Department Note indicated the following: “10-year-old ...brought in by mother ambulatory ...with complaint of coughing, shortness of breath, sore throat since last night ...” Medical Decision Making: Patient 8 was given Rocephin (an antibiotic used to treat bacterial infections and. Zithromax (an antibiotic to treat a wide range of bacterial infections). Patient 8 was also given Solu-Medrol (an injectable corticosteroid used to treat severe inflammation), Xopenex (a short-acting bronchodilator [rescue medication] to treat sudden airway tightening) handheld nebulizer breathing treatment, and oxygen increased to 4 Liters (L) via facemask. Diagnosis: acute Bronchopneumonia (a lung infection causing inflammation in patches in the long and nearby tissue), hypoxemia (low oxygen levels in the blood), and dyspnea (shortness of breath). During a review of Patient 8’s “Ambulatory Assessment,” dated 8/24/2025 at 10:02 p.m., the Ambulatory Assessment indicated the following: At 8:25 p.m. “Gave transfer patient report to RN.” Accepting facility was Hospital C. Disposition: Transferred on 8/24/2025 at 9:33 p.m., to acute care hospital. During a review of Patient 8’s “EMTALA Patient Transfer Form,” dated 8/24/2025, the EMTALA Patient Transfer Form indicated Patient 8 was being transferred. The name of the receiving facility was not documented, instead, the name of facility was documented as “Long Beach,” the name of a city. In addition, Patient 2’s condition was blank, not documented. The Section titled, “Physician Certification - Transfer Acknowledgement & Consent,” was blank. It did not indicate whether Patient 8’s emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and the parent for Patient 8, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there...) of the transfer were not specified or marked on the document. During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, Patient 8’s EMTALA Patient Transfer Form, was reviewed. CARN 1 stated that the form was incomplete. CARN 1 stated Patient 8 was transferred to another facility because Patient 8 was a pediatric (ages birth to 18 - 21 years old) patient. Patient 8’s condition upon transfer was not documented. The form was signed by the physician and the Patient 8’s parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 8’s emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 8. CARN 1 stated she did not know Patient 8’s condition upon transfer. CARN 1 also acknowledged that the name of the receiving facility was not documented on the form. During a review of Patient 9’s “Emergency Department Triage,” dated 8/24/2025 at 12:10 p.m., the Emergency Department Triage record indicated the following: Patient 9 arrived at the Emergency Department (ED) from home accompanied by a parent (s). Per parents, Patient 9 complained of vomiting and diarrhea since the day prior (8/23/2025). During a review of Patient 9 ‘s “Emergency Department Note,” dated 8/24/2025 at 12:10 p.m., the Emergency Department Note indicated the following: “2-year-old ...brought by parents with complaint of nausea, vomiting, diarrhea since last night ...Medical decision making: Result the work up reviewed case, discussed with accepting physician (AMD 2), pediatrician, at Hospital C, who accepts patient (Patient 9) for transfer ...Diagnosis: Acute Gastroenteritis (inflammation of the stomach or intestines, often call “stomach flu”) and dehydration (the body does not have enough water or fluid to function properly).” During a review of Patient 9’s “EMTALA Patient Transfer Form,” dated 8/24/2025 at 3:30p.m., the EMTALA Patient Transfer Form indicated Patient 9 was being transferred due to Patient 9 being a pediatric patient. The name of the receiving facility was not documented instead, the name of facility was documented as “Long Beach,” the name of a city. The Section titled, “Physician Certification - Transfer Acknowledgement & Consent,” was blank. It did not indicate whether Patient 9’s emergency medical condition was stabilized or not stabilized. The Form was signed by the physician and Patient 9’s parent, however, the risk (death, worsening condition, low risk, or other) and benefits (specialized treatment or my physicians are there ...) of the transfer were not specified or marked on the document. During a concurrent interview and record review on 12/23/2025 at 9:49 a.m. with CARN 1, CARN 1 stated the following: Patient 9 was transferred to another hospital because Patient 9 was a pediatric patient. CARN 1 verified that Patient 9’s EMTALA Patient Transfer Form was incomplete. The name of the receiving facility was not documented, only the name of the city (Long Beach) in which the hospital was located was documented. The form did not indicate the mode of transportation (ambulance or paramedics). The form was signed by the physician and Patient 9’s parent, however, the Physician Certification - Transfer Acknowledgement & Consent was blank. It did not indicate whether Patient 9’s emergency medical condition was stabilized or not stabilized. In addition, it did not indicate the risk and benefits of transferring Patient 9. CARN 1 stated it was very important to document the patients’ condition and mode of transportation upon transfer to ensure safe and appropriate transfer. During a review of Patient 14’s “Emergency Department Triage,” dated 7/25/2025 at 2:11 p.m., the Emergency Department Triage record indicated the following: Patient 14 arrived by ambulance from a skilled nursing facility to Emergency Department (ED) with a chief complaint for aggressive behavior and being assaultive towards staff. Patient 14 needed to be medically clear and then transferred to another hospital (receiving facility, Hospital D). During a review of Patient 14’s “Emergency Department Note,” dated 7/25/2025 at 2:14 p.m., the Emergency Department Note indicated the following: Patient 14 was from a nursing home with complaints of bizarre behavior and aggressive behavior toward staff. Patient 14’s Neurological assessment was alert and oriented to person, place, and time. Patient 14 was diagnosed with Psychotic behavior (involves a loss of contact with reality, characterized by distorted thinking, perceptions, and behaviors, primarily seen through hallucinations [seeing/hearing things not there] and delusions [false, fixed beliefs]) and was medically cleared to go to psychiatric hospital. During a review of Patient 14’s “Progress Notes Report,” dated 7/25/2025 at 9:03 p.m., the Progress Notes Report indicated the following: Patient 14 was transferred by ambulance. During an interview on 12/23/2025 at 10:26 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no “Transfer form” documentation in the medical chart for Patient 14. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to patient. There was no documentation of accepting representatives at the accepting facility. During a review of Patient 15’s “Emergency Department Triage,” dated 7/24/2025 at 11:19 p.m., the Emergency Department Triage record indicated the following: Patient 15 arrived in the Emergency Department (ED) accompanied by Deputy with a chief complaint of suicidal ideation (thoughts of considering death) and on a 5150 hold (a legal provision allowing police or mental health professionals to involuntarily detain someone for up to 72 hours for a psychiatric evaluation if they’re deemed a danger to themselves or others, or are gravely disabled due to a mental health crisis, enabling stabilization and assessment before potential release or further involuntary holds). During a review of Patient 15’s “Emergency Department Note,” dated 7/24/2025 at 11:19 p.m., the Emergency Department Note indicated the following: Patient 15 was a minor and got into verbal altercation at home and had thoughts of hurting self. Patient 15 was on a 5150 hold. Patient 15 needed to be transferred to Behavioral Health Unit (a specialized, secure hospital unit or facility designed to provide 24/7 care, stabilization, and treatment for individuals experiencing acute mental health crises, severe psychiatric disorders, or substance abuse issues) for evaluation. During a review of Patient 15’s “Progress Notes Report,” dated 7/25/2025 at 4:09 p.m., the Progress Notes Report indicated the following: Patient 15 was transferred to another facility (receiving facility, Hospital E). During an interview on 12/23/2025 at 10:36 a.m. with the Clinical Analyst Registered Nurse 2 (CARN 2), CARN 2 confirmed the following: There was no “Transfer form” documentation in the medical chart for Patient 15. No documentation signed Physician Certification of condition of patient, explaining the risk and benefits of transfer to the patient. No documentation regarding accepting representatives at the accepting facility. During a review of the facility’s policy and procedure (P&P) titled, “EMTALA Guidelines for Emergency Department,” dated 8/2022, the P&P indicated the following: Transfer For Care Outside the Hospital: a. Unable Patients: An individual with an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity [including severe pain ...] such as the absence of immediate medical attention could reasonably be expected to result in: ...Placing the health of an individual in serious jeopardy; serious impairment of bodily functions; serious dysfunction of any bodily organ or part) which has not been stabilized may only be transferred for medical reasons or if the individual makes an informed request for transfer ...2. For Medical Reasons With Physician Certification: If the physician certifies in wring on the “Transfer Summary Form,” that, based on the reasonable risk and benefits to the patient, and based upon the information available at the time of the patient’s transfer, the medical benefits reasonably expected for the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the patient and, if pregnant, the patient’s unborn child from effecting the transfer. b. Stable Patients: Individuals who have an EMC which has been stabilized, i.e., who is Stable for Transfer, may be transferred to another facility for definite care under one of the following: ...Recommend Transfer For Medical Reasons: If a physician recommends the transfer based on the medical benefits and the individual provides informed consent to the transfer, the transfer may then occur if the individual or legally responsible person (LRP) consents to the transfer and acknowledges the reasons for the transfer and his/her awareness of the risk and benefits of the transfer on the “Transfer Summary Form.” Patient Transfer: It is the responsibility of the physician to ensure that all transfers for immediate care of an individual to another care facility will be carried out in accordance with the following: 1. Medical Treatment: The hospital will provide, within its capacity, medical treatment that minimizes the risk of transfer/referral to the individual’s health ... 2. Informed Consent: Where the transfer is medically recommended, the hospital will notify the individual or, where applicable, the individual’s LRP, both orally and in writing of the recommend transfer and reasons therefore ... 3. Informed Request: Where the transfer is in response to a request for the transfer by the individual, such request must be documented on the “Transfer Summary Form” and signed by the individual or the LRP ... a. For non-medical transfer, the “Transfer Summary Form,” must include a declaration by the physician that the individual is Stable for Transfer, and an acknowledgement by the individual or LRP that he/she has been offered continuing care at the facility, as well as the risk of the transfer and the reasons for the transfer. b. For transfers of individuals who have not been stabilized, the individual must acknowledge on the “Transfer Summary Form,” the risk of the transfer, his/her right to recommended treatment at the facility and the reasons for the requested transfer. 4. Contact Receiving Facility. A representative of the receiving facility must have confirmed that: a. The receiving facility has available space and qualified personnel to treat the individual; and b. The receiving facility has agreed to accept transfer of the individual and to provide appropriate medical treatment. 5. Copies of Medical Records/Consents/Certification, the Hospital will send the receiving facility copies of all pertinent medical records available at transfer, including: a. History b. Records related to the individual’s emergency medical condition. c. Observations of signs and symptoms; d. Preliminary diagnosis; e. Results of diagnostic studies or telephone reports of the studies; f. Treatment provided; g. Results of any tests; and h. A copy of the informed written request or certification and consent to transfer. 6. Transport By - Qualified Personnel: The transfer will be effected through qualified personnel and transportation equipment, as determined by the physician included the use of necessary and medically appropriate life support measures during the transfer ... 7. Complete Transfer Summary: The ED Physician shall ensure that a completed “Transfer Summary Form,” signed by the patient or legally responsible adult ... During a review of the facility’s policy and procedure (P&P) titled, “Higher Level of Care Transfers,” dated 11/2025, the P&P indicated the following: Under the direction of the Emergency Department (ED) Physician, Patients, requiring higher level of service will be appropriately transferred from the Emergency Department ...Higher level of care is defined as a level of care which cannot be provided at the Hospital. Procedure: Emergency Department Physician advises and documents need for transfer to higher level of care ...Once a facility accepts the patient, ED physician and ED clerk are informed by the charge registered nurse. As appropriate, patient / family members are advised of transfer. Arrangements are made for transportation. All appropriate documentation is on the E.D. (Emergency Department) Summary, Nurses’ Progress Notes and EMTALA Patient Transfer Form.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45743 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met, as evidenced by: 1. The facility failed to ensure a safe environment in the facility’s Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), when there was no proper rounding (the process of regularly visiting patients to assess their condition) conducted, every 15 minutes (Q15min), for 15 of 46 sampled patients (Patients 1-15), in the BHU, to check on the patients’ location, behavior, and environmental or personal safety, on 8/26/2025 from 11:00 p.m. to 8/27/2025 at 7:00 a.m., in accordance with the facility’s policy regarding rounding, observation, and monitoring patients, who were admitted to the BHU. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent) by Patient 2 without the facility’s knowledge on when and how it happened. (Refer to A-0144) 2. The facility failed to ensure a safe environment in the facility’s Behavioral Health Unit (BHU) when there was no proper line of sight (a straight line along which an observer had unobstructed vision) and Q (every) 15 minutes rounding, conducted for 21 of 46 sampled patients (Patient 2, Patient 7, Patient 16 -35), on 9/6/2025 from 6:00 p.m. to 9:30 p.m., in accordance with the facility’s policy regarding rounding, observation, and monitoring patients, who are admitted to the BHU. This deficient practice potentially placed 21 patients’ safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done), violence, and/or death. (Refer to A-0144) 3. The facility failed to ensure one (1) of 46 sampled patients (Patient 1) was free from all forms abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy on patient rights (a subset of human rights), when an allegation of sexual assault was made by Patient 1 on 8/27/2025. This deficient practice had the potential for Patient 1 and other patients in the Behavioral Health Unit (BHU) to experience physical injury, psychological trauma, fear, or anxiety (persistent worry or fear), and may lose trust in healthcare providers and institutions. (Refer to A-0145) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45743 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure adequate supervision of the facility’s Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff that included Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and the Behavioral health Technicians (BHTs), to ensure consistent and accurate Q (every) 15-minute patient rounding (the process of regularly visiting patients to assess their condition) for 15 of 46 sampled patients (Patients 1-15), in accordance with the facility’s policy regarding “Rounding, Observation, and Monitoring of Patients.” This deficient practice had the potential to place patients at risk for suicide (thoughts of taking one’s own life), self-harm, assault (an intentional act that causes a reasonable fear of immediate harmful or offensive contact, even if no physical contact actually occurs), or undetected medical emergencies, by leaving patients unsupervised for extended periods. (A-0395) 2. The facility failed to ensure nursing staff adequately assessed a patient’s care needs and addressed, in a timely manner, one of 46 sampled patient’s (Patient 39) low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs), by calling for a Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration), in accordance with the facility’s policy regarding calling a RRT and policy on Standards of Nursing Practice pertaining to the nursing care process. Patient 39 had a persistently low blood pressure for over 3 hours in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), on 5/26/2025, before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries). This deficient practice resulted in Patient 39 having a delay in further evaluation and treatment, when Patient 39 remained in the Telemetry unit for more than three hours before being transferred to the Intensive Care Unit (ICU), which could have led to further complications and/or death. (Refer to A-0395) 3. The facility failed to ensure nursing staff adhered to the facility’s policy and procedure regarding “Rounding, Observation and Monitoring of Patients,” and the facility’s charting/documentation policy, when staff did not perform and accurately document the Q (every) 15-minute rounding (observing patient location and behavior), for 15 of 46 sampled patients (Patients 1-15), from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent) by Patient 2 without the facility’s knowledge on when and how it happened. (Refer to A-0398) 4. The facility failed to ensure a concern of low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs) lasting over several hours (3 hours), for one of 46 sampled patients (Patient 39), was escalated by using a Rapid Response Team (RRT, group of individuals [may include a nurse, respiratory therapist, physician] that responds to concerning or emergency situations and can provide additional evaluations and interventions), in accordance with the facility’s policy and procedure regarding “Rapid Response Team (RRT).” This deficient practice resulted in Patient 39, remaining in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), with persistent low blood pressure for more than three hours, before being transferred to a higher level of care (a more intensive and comprehensive level of medical health treatment), which delayed treatment and could have worsened Patient 39’s condition. (Refer to A-0398) 4. The facility failed to ensure an Oxygen Tank (a device to provide respiratory [to breathe] support) was stored and readily available for immediate use on one of two sampled crash carts (Cart #1, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment), in the Emergency Department (ED, a specialized hospital unit that provides 24/7 unscheduled medical care for acute [sudden in onset], severe, and life-threatening injuries and illnesses), which may impact 46 of 46 sampled patients, in accordance with the facility’s policy regarding crash cart equipment and medications. This deficient practice had the potential to result in endangering patients’ life by delaying the ability to provide respiratory support (medical interventions that assist a patient’s breathing when they are unable to do so adequately on their own. Example: providing oxygen therapy from an oxygen tank) in an emergency, which may result in patient harm and/or death. (Refer to A-0398) 5. The facility failed to ensure staff followed the facility’s “Peripheral Inserted Central Catheter: Assisting, Insertion, Care and Removal Policy,” for 2 of 46 sampled patients (Patient 44 and Patient 45), when staff did not provide proper PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large, significant vein responsible for returning deoxygenated blood collected from the body to the heart], and used for intravenous treatment that is required over a long period) care by not changing Patient 44’s soiled PICC line dressing and not properly securing Patient 45’s PICC line with a securement device. This deficient practice had the potential for Patient 44 and Patient 45 to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper maintenance and care of PICC line. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 45743 Based on observation, interview and record review, the facility’s Governing Body (GB, the group of individuals legally responsible for overseeing the hospital, including ensuring that policies are followed, resources are provided, and patient safety is protected) failed to: 1. Ensure oversight on the Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) team so that a comprehensive action plan to assure a safe environment and that patients remain free of abuse (intentional maltreatment of an individual that may cause physical or psychological injury), was implemented. The action plan implemented immediately after the alleged incident of sexual abuse on 8/27/2025, involving one (1) of 46 sampled patients, included incomplete in-service regarding proper patient rounding (not all staff working received in-service since 8/28/2025), and the in-service plan did not include the role of the RN and Charge nurse to ensure compliance (of Licensed Vocational Nurses [LVNs] and Behavioral Health Technicians [BHTs]) with patient rounding (the process of regularly visiting patients to assess their condition). The QAPI team did not also implement proper auditing process to determine if rounding is being done consistently and accurately, in accordance with the facility’s policy regarding rounding and observation of patients, the facility’s patient safety plan and the facility’s Governing Body Bylaws (the facility’s formal written rules that define its purpose, powers, and responsibilities. These bylaws require the Governing body to maintain ultimate accountability for the safety and quality of care, oversee hospital compliance with all laws and regulations, and ensure that the facility policies are implemented effectively to protect patients). This deficient practice had the potential to cause serious harm or death when high-risk patients (patients who may be at risk of harm themselves, harming others, or experiencing a sudden medical emergency) are left unchecked for extended periods, thus increasing the risk of suicide (thoughts of taking one’s own life) , self-harm, assault (to attack), or undetected medical emergencies. 2. Ensure oversight on the Nursing Department to ensure that staff (RNs, LVNs [Licensed Vocational Nurses], BHTs [Behavioral health Technicians]) working in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) were completing line-of-sight (a straight line along which an observer had unobstructed vision) and Q15 minutes (every 15 minutes) patient rounding, in accordance with the facility’s policy regarding patient rounding, for 15 of 46 sampled patients (Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15) on 8/27/2025 and 21 of 46 sampled patients (Patient 2, Patient 17, Patients 16-34) on 9/6/2025. This deficient practice resulted in a sexual assault allegation involving Patients 1 (alleged victim) and 2 (alleged perpetrator) on 8/27/2025. This deficient practice also had the potential to cause serious harm or death when high-risk patients (patients who may be at risk of harm themselves, harming others, or experiencing a sudden medical emergency) are left unchecked for extended periods, thus increasing the risk of suicide (thoughts of taking one’s own life) , self-harm, assault (to attack), or undetected medical emergencies. Findings: 1. During a review of Patient 1’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Progress Note,” dated 8/27/2025, the psychiatric progress note indicated, “This morning the patient (Patient 1) was anxious (feeling tense, on edge, restless, fearful), rambling at times, fixated on discharge. He (Patient 1) endorsed being sexually assaulted by his roommate (Patient 2), police department came to interview and Sexual Assault Response Team (SART, provides emotional support, advocacy, and access to victim assistance services) nurse made recommendations made by medical and nursing staff.” During a review of Patient 1’s “Progress Notes Report,” dated 8/27/2025, the record indicated Patient 1’s “Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person’s emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell).” The record further indicated at 8:53 a.m., on 8/27/2025, Patient 1 “Approached primary nurse and claimed that he (Patient 1) was raped by his (Patient 1) roommate (Patient 2) last night.” During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed: -At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed. -At 12:00 a.m., on 8/27/2025, no rounding was observed. -At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted -At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient. -At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients. -At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room. -At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed. -At 2:13 a.m., Patient 2 was seen going in and out of his (Patient 2) room. -At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m. -At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed. During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients’ door, check for patients’ breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed (RNs and LVNs) staff every 2 hours. During a record review of the facility’s documents titled, “Inservice Roster: Topic Rounding, Observation and Monitoring of Patients,” dated 8/28/2025, 8/29/2025-8/30/2025 and 9/9/2025, the in-service roster indicated that 68 out of a total of 131 Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff members had been in-serviced regarding the BHU’s policy titled, “Rounding, Observation, and Monitoring of Patients.” During a record review of the facility’s document titled, “Behavioral Health Unit staffing sheet,” dated 9/10/2025, the document indicated the following: -For the 7AM to 7PM shift, a total of 10 out of 14 BHU staff members have attended the in-service regarding patient rounding. -For the 7PM to 7AM shift, a total of 5 out of 19 BHU staff members have attended the in-service regarding patient rounding. During a concurrent observation, interview and record review on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the Director of Behavioral health Unit (DBHU), the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The Video Footage of 21 Patients (Patient 2, Patient 7, Patient 16 to Patient 34) indicated that all 21 patients were not rounded on/monitored consistently and accurately (despite the in-services regarding patient rounding that were conducted by the facility). Behavioral Health Technician (BHT) 4, BHT 5 and Licensed Vocational Nurse (LVN) 1 were observed using their phone, not properly rounding on patients, not opening patient’s doors, skipping rooms, and no RN oversight, was observed. This was confirmed by the Director of BHU (DBHU). During an interview on 9/9/2025 at 3:57 p.m. with the DBHU, the DBHU stated that in-service training for patient rounding was still on going and not all BHU staff have completed the in-service. During an interview on 9/11/2025 at 9 a.m. with the Quality Risk Management Director (QRMD), the QRMD stated the following: The facility provided in-service training, on 8/28/2025, for patient rounding every 15 minutes, after the first CDPH (California Department of Public Health, a regulatory agency) surveyor initially investigated the allegation of sexual abuse made by Patient 1 on 8/27/2025. The QRMD stated the night shift staff were not conducting their rounds every 15 minutes. The QRMD also stated that even though patient rounding training had been provided, staff were still not conducting the rounds properly. During an interview on 9/11/2025 at 10:07 a.m. with DBHU, DBHU stated when he (DBHU) comes in around 7:00 a.m. to 8:00 a.m., he (DBHU) requests a copy of the rounding sheets to make sure they’re filled. He checks the rounding sheets with the video snippets and did not keep track of the videos he watched. DBHU stated he ensured the RNs were rounding by trying to look at specific times and at 15-minute portions. DBHU stated he (DBHU) did not have time to review a whole time period such as an hour, and the least amount of time he (DBHU) watched was 15 minutes. DBHU stated if he (DBHU) had more time he would watch another time period for 15 minutes. DBHU stated he trusted that he (DBHU) would see the staff conduct patient rounds. DBHU stated he ensured weekend staff was rounding by reinforcing rounding to all staff. During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1’s and BHT 2’s Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). During an interview on 9/11/2025 at 10:16 a.m. with the Director of the Behavioral Health Unit (DBHU), the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault made by Patient 1’s significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. DBHU verified that no rounds (Q15 min) were conducted that night, 8/26/2025 from 11 p.m. to 8/27/2025 at 7 a.m., by the Behavioral Health Technicians (BHT) and Registered Nurses (RNs). The BHT falsified the rounding sheets and BHTs acknowledged it (the falsified data of Q 15-minute rounding). Medical records were supposed to be accurate. The DBHU asked the charge nurses to make sure rounding was being done on time. The DBHU requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding. During an interview on 9/12/2025 at 3:18 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: The Governing Body (GB, the group of individuals legally responsible for overseeing the hospital, including ensuring that policies are followed, resources are provided, and patient safety is protected) was not aware there were issues with patient safety rounds, or inaccurate documentation of the safety rounds. The Governing Body was only aware after the alleged incident between Patient 1 and Patient 2 which occurred on 8/27/2025. The CEO also said that video surveillance of patient rounding was sporadically reviewed and only reviewed if an incident occurred. The CEO stated QAPI (Quality Assurance and Performance Improvement, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) should communicate with the GB regarding any patient safety issues and QAPI should ensure action plans are effective and in place. The CEO further stated the Governing Body had authority for overall operations of the hospital, including patient safety. During an interview on 9/12/2025 at 4:17 p.m. with Quality Risk Management Director (QRMD), QRMD stated the whole hospital was involved in ensuring patient safety and all patient care departments (such as the Nursing Department) report to the QAPI department quarterly, and the data (QAPI initiatives such as CLABSIs and any patient safety issues) was then reported by the QAPI to the Medical Executive Committee (represents the medical staff, oversees quality of care, ensures professional conduct, and makes key recommendations to the hospital’s administration and board of directors) and the Governing Body because the GB had oversight over QAPI (the committee in which the QRMD is part of and responsible for performance improvement activities, track adverse patient events and other patient safety issues, analyze the causes, implement preventive action plans, and audit mechanisms to ensure compliance and continuous improvement). QRMD stated the Patient rounding video footage for the whole night (on 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m.), was not thoroughly reviewed or analyzed in its entirety, because it was not under their (referring to the QAPI) scope of work (The QRMD relied on the DBHU to complete the video footage review on patient rounding. This lack of coordinated effort between the DBHU and the QRMD does not align with the facility’s “patient safety plan” regarding creating procedures for responding to system or process failures and the facility’s “patient safety plan” that indicated “All hospital departments, programs, and services participate in the patient safety program”). During a review of the facility’s “Governing Board of Directors Bylaws (the facility’s formal written rules that define its purpose, powers, and responsibilities. These bylaws require the Governing Body to maintain ultimate accountability for the safety and quality of care, oversee hospital compliance with all laws and regulations, and ensure that the facility policies are implemented effectively to protect patients),” dated 02/08/2024. The facility’s GB bylaws indicated, “The purpose of the Hospital Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management, and planning of the Hospital. The Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment, and services rendered in the Hospital. During a review of the facility’s policy and procedure (P&P) titled, “Patient Safety Plan,” dated 9/2025, the P&P indicated, “The Patient Safety Plan is a framework to establish and maintain a safe patient care environment. It expands the organization-wide support for risk management, performance improvement, information management, education, human resources, and patient rights by implementing patient safety standards, measuring, monitoring their effectiveness, and creating a “culture of safety” as part of the overall quality program ...The scope of the patient safety program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events. All hospital departments, programs, and services participate in the patient safety program. As part of the patient safety program, the hospital creates procedures for responding to system or process failures.” 2. During a review of Patient 1’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Progress Note,” dated 8/27/2025, the psychiatric progress note indicated, “This morning the patient (Patient 1) was anxious (feeling tense, on edge, restless, fearful), rambling at times, fixated on discharge. He (Patient 1) endorsed being sexually assaulted by his roommate (Patient 2), police department came to interview and Sexual Assault Response Team (SART, provides emotional support, advocacy, and access to victim assistance services) nurse made recommendations made by medical and nursing staff.” During a review of Patient 1’s “Progress Notes Report,” dated 8/27/2025, the record indicated Patient 1’s “Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person’s emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell).” The record further indicated at 8:53 a.m., on 8/27/2025, Patient 1 “Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night.” During a review of Patient 1’s “Progress Note,” dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both verbalized understanding of discharge instructions. During a review of Patient 2’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable) and suicidal ideations (thoughts of taking one’s own life). During a review of Patient 2’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient’s location and activity) and was on suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious. During a review of Patient 2’s “Psychiatric Discharge Note,” dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025. During a review of Patients 1 and 2’s document titled, “BHU Q (every) 15 Minute Roundings and Observation Form,” dated 8/26/2025, the form indicated from times 2300 (11:00 p.m.) to 0700 (7:00 a.m.), Patients 1 and 2’s behavior was documented asleep/breathing. During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed: -At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed. -At 12:00 a.m., on 8/27/2025, no rounding was observed. -At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted -At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient. -At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients. -At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room. -At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed. -At 2:13 a.m., Patient 2 was seen going in and out of his room. -At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m. -At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed. During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients’ door, check for patients’ breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed (RNs and LVNs) staff every 2 hours. During an interview on 9/9/2025 at 3:57 p.m. with the DBHU, the DBHU stated that in-service training regarding patient rounding compliance was still on going and not all BHU staff have completed the in-service. The DBHU stated that the goal was to have all staff in-serviced as soon as possible. During an interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1’s and BHT 2’s Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). The DBHU said he (DBHU) asked the charge nurses to make sure rounding was being done on time. The DBHU requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding. During the same interview on 9/11/2025 at 10:07 a.m. the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault made by Patient 1’s significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. The DBHU stated that Patient 1 repeatedly verbalized “I just want to go home.” During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1’s and BHT 2’s Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). During a concurrent observation, interview and record review on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the Director of Behavioral health Unit (DBHU), the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The Video Footage of 21 Patients (Patient 2, Patient 7, Patient 16 to Patient 34) indicated that all 21 patients were not rounded on/monitored consistently and accurately (despite the in-services regarding patient rounding that were conducted by the facility). Behavioral Health Technician (BHT) 4, BHT 5 and Licensed Vocational Nurse (LVN) 1 were observed using their phone, not properly rounding on patients, not opening patient’s doors, skipping rooms, and no RN oversight, was observed. This was confirmed by the Director of BHU (DBHU). During a concurrent interview and record review on 9/10/2025 at 3:02 p.m. with the Clinical Analyst Information Technology (CAIT) and Registered Nurse (RN) 4, Patient 1’s “Electronic Medical Record,” undated, was reviewed. CAIT confirmed that Patient 1 was discharged on 8/28/2025 at 11:15 a.m. During an interview on 9/10/2025 at 3:20 p.m. with RN 4 and CAIT, Patient 2’s “Electronic Medical Record,” undated, was reviewed. CAIT confirmed that Patient 2 was discharged on 8/28/2025 at 11:35 a.m. During an interview on 9/11/2025 at 10:07 a.m. with the DBHU, the DBHU stated he (DBHU) checked the rounding sheets with the video snippets and did not keep track of the videos he watched and trusted he (DBHU) would see the staff conducting patient rounds. DBHU stated he (DBHU) ensured weekend staff were rounding by reinforcing patient rounding to all staff. During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU stated he (DBHU) did not see the actual Sexual Assault Response Team report ([SART report- document detailing a forensic medical exam of a sexual assault victim]). DBHU was told by the SART nurse that it did not seem like there was abuse, and that the alleged victim (Patient 1) did not want to file any charges. DBHU stated he (DBHU) did not have the official report from the forensic nurse confirming whether or not the allegation occurred. During an interview on 9/12/2025 at 11:58 a.m. with Quality Risk Management Director (QRMD), QRMD stated Patients 1 and 2 were discharged and the facility could not continue with the investigation after Patients 1 and 2 were discharged. During an interview on 9/12/2025 at 4:17 p.m. with Quality Risk Management Director (QRMD), QRMD stated the whole hospital was involved in ensuring patient safety and all patient care departments (such as the Nursing department) report to the QAPI department quarterly, and the data (QAPI initiatives such as CLABSIs and any patient safety issues) was then reported by QAPI to the Medical Executive Committee (represents the medical staff, oversees quality of care, ensures professional conduct, and makes key recommendations to the hospital’s administration and board of directors) and the Governing Body because the GB had oversight over QAPI (the committee in which the QRMD is part of and responsible for performance improvement activities, track adverse patient events and other patient safety issues, analyze the causes, implement preventive action plans, and audit mechanisms to ensure compliance and continuous improvement). QRMD stated the Patient rounding video footage for the whole night (on 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m.), was not thoroughly reviewed or analyzed in its entirety, because it was not under their (referring to the QAPI) scope of work (The QRMD relied on the DBHU [from the Nursing Department] to complete the video footage review on patient rounding. This lack of coordinated effort between the DBHU and the QRMD does not align with the facility’s “patient safety plan” regarding creating procedures for responding to system or process failures and the facility’s “patient safety plan” that indicated “All hospital departments, programs, and services participate in the patient safety program”). During a review of the facility’s “Governing Board of Directors Bylaws (the facility’s formal written rules that define its purpose, powers, and responsibilities. These bylaws require the Governing body to maintain ultimate accountability for the safety and quality of care, oversee hospital compliance with all laws and regulations, and ensure that the facility policies are implemented effectively to protect patients),” dated 02/08/2024. The facility’s GB bylaws indicated, “The purpose of the Hospital Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management, and planning of the Hospital. The Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment, and services rendered in the Hospital. During a review of the facility’s policy and procedure (P&P) titled, “Patient Safety Plan,” dated 9/2025, the P&P indicated, “The Patient Safety Plan is a framework to establish and maintain a safe patient care environment. It expands the organization-wide support for risk management, performance improvement, information management, education, human resources, and patient rights by implementing patient safety standards, measuring, monitoring their effectiveness, and creating a “culture of safety” as part of the overall quality program...The scope of the patient safety program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events. All hospital departments, programs, and services participate in the patient safety program. As part of the patient safety program, the hospital creates procedures for responding to system or process failures.” During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 09/2022, the P&P indicated, “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ...””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45743 Based on observation, interview and record review, the facility failed to ensure a safe environment in the facility’s Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) when: 1. There was no proper rounding (the process of regularly visiting patients to assess their condition) conducted, every 15 minutes (Q 15-min), for 15 of 46 sampled patients (Patients 1-15), in the BHU, to check on the patients’ location, behavior, and environmental or personal safety, on 8/26/2025 from 11:00 p.m. to 8/27/2025 at 7:00 a.m., in accordance with the facility’s policy regarding rounding, observation, and monitoring patients, who are admitted to the BHU. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent) by Patient 2 without the facility’s knowledge on when and how it happened. 2. There was no proper line of sight (a straight line along which an observer had unobstructed vision) and Q (every) 15 minutes rounding, conducted for 21 of 46 sampled patients (Patient 2, Patient 7, Patient 16 -35), on 9/6/2025 from 6:00 p.m. to 9:30 p.m., in accordance with the facility’s policy regarding rounding, observation, and monitoring patients, who are admitted to the BHU. This deficient practice placed 21 patients’ safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done), violence, and/or death. Findings: 1. During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one’s own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient’s location and activity) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions. During a review of Patient 1’s document titled, “Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form,” dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1’s behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m. During a review of Patient 1’s “Progress Notes Report,” dated 8/27/2025, the record indicated Patient 1’s “Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person’s emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell).” The record further indicated at 8:53 a.m., Patient 1 “Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night.” During a review of Patient 1’s “Progress Note,” dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1’s family) verbalized understanding of discharge instructions. During a review of Patient 2’s H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations. During a review of Patient 2’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient’s location and activity) and was on suicide/self-harm and fall (an unintentional descent of a patient to the ground, floor, or another lower surface) precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious. During a review of Patient 2’s “Psychiatric Discharge Note,” dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025. During a review of Patient 3’s H&P, dated 8/25/2025, the H&P indicated Patient 3 was admitted to the facility on 8/25/2025. The H&P also indicated Patient 3 had depression with suicidal ideations. During a review of Patient 3’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 3 was on standard observation and was on suicide/self-harm and fall precautions (a set of preventive measures to prevent patient injuries, such as bruises, fractures [broken bones], and even death, by reducing the frequency and severity of falls). During a review of Patient 4’s H&P, dated 8/25/2025, the H&P indicated Patient 4 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 4 was on a 5150 (72-hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal and homicidal ideations (thoughts of killing others). The H&P indicated Patient 4 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 4’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 at 8 a.m. and 12 p.m., the document indicated Patient 4 was hopeless/helpless and socially withdrawn. On 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 4 was in a depressed mood. During a review of Patient 5’s H&P, dated 8/24/2025, the H&P indicated Patient 5 was admitted to the facility on 8/23/2025 for schizophrenia (person loses touch with reality, experiencing things like false beliefs [delusions], seeing or hearing things that aren’t there [hallucinations]), disorganized thinking and speech, and withdrawal from others. The H&P indicated Patient 5 was placed on a 5150 hold for being a danger to others and hearing voices. During a review of Patient 5’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 5 was on standard observation and on suicide/self-harm and fall precautions. During a review of Patient 6’s H&P, dated 8/24/2025, the H&P indicated Patient 6 was admitted to the facility on 8/23/2025 for anxiety. The H&P also indicated Patient 6 had a chief complaint of being a danger to others and mental breakdown. During a review of Patient 6’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025, the H&P indicated that on 8/26/2025, Patient 6 was placed under 1:1 (healthcare individual stays with the patient as a safety precaution) Arms-Length observation (a staff member remains within arm’s reach of the patient at all times, providing immediate intervention and care, especially when a patient poses a risk to themselves or others due to mental distress or health concerns) until 2:01 p.m. On 8/26/2025 at 2:01 p.m., Patient 6 was placed under Line of Sight (direct view of patient) observation. On 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., Patient 6 was on suicide/self-harm and fall precautions. The roundings and observation form further indicated that on 8/26/2025, Patient 6 was anxious at 9:30 a.m., 9:45 a.m., 11 a.m., 11:15 a.m., and 12:45 p.m. In addition, Patient 6 was also agitated and hostile at 8 a.m. and hostile at 12 p.m. on 8/26/2025. During a review of Patient 7’s H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 7’s chief complaint was major depression with suicide ideations with plan to overdose on fentanyl (pain killer medication). During a review of Patient 7’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 8’s H&P, dated 8/22/2025, the H&P indicated Patient 8 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 8 presented with suicidal ideations and major depressive disorder. During a review of Patient 8’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 8 was placed under standard observation and on suicide/self-harm precautions. During a review of Patient 9’s H&P, dated 8/22/2025, the H&P indicated Patient 9 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 9 presented with suicidal ideations with plan to overdose. During a review of Patient 9’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 9 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 10’s H&P, dated 8/21/2025, the H&P indicated Patient 10 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 10 had depression. During a review of Patient 10’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 10 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 11’s H&P, dated 8/21/2025, the H&P indicated Patient 11 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 11 had suicidal ideations and had a history of schizoaffective disorder (impaired ability to distinguish reality from what is not real). During a review of Patient 11’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 11 was placed under standard observation and on suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 11’s behavior was intrusive at 7:45 a.m., 8 a.m., 8:15 a.m., and 8:30 a.m. on 8/27/2025. During a review of Patient 12’s H&P, dated 8/22/2025, the H&P indicated Patient 12 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 12 was brought by an outside acute care hospital (a healthcare facility that provides short-term, intensive medical and surgical care for patients with acute illnesses or injuries) with complaints of “hurting others with a plan to shoot them.” During a review of Patient 12’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 12 was under standard observation and under suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 12 was agitated (feeling of irritation and restlessness) on 8/26/2025 at 8 a.m., and anxious at 8:15 a.m. and 9:15 a.m. on 8/26/2025. During a review of Patient 13’s H&P, dated 8/21/2025, the H&P indicated Patient 13 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 13 was gravely disabled (unable to take care of themselves) and a danger to others. During a review of Patient 13’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 13 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 14’s H&P, dated 8/20/2025, the H&P indicated Patient 14 was admitted to the facility on 8/20/2025. The H&P further indicated Patient 14 had suicidal ideations. During a review of Patient 14’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 14 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 15’s H&P, dated 8/22/2025, the H&P indicated Patient 15 was admitted to the facility on 8/19/2025. The H&P further indicated Patient 15 had suicidal ideations and a history of schizophrenia. During a review of Patient 15’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the roundings and observation form indicated Patient 15 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patients’ 1-15’s document titled, “BHU Q 15 Minute Roundings and Observation Form,” dated 8/26/2025, the document indicated from times 2300 (11:00 p.m.) on 8/26/2025 to 0700 (7:00 a.m.) on 8/27/2025, Patients’ 1-15’s behavior was documented asleep/breathing. During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated “we (BHT) observe patients every 15 minutes (Q15), and check for patients’ breathing, location and patients’ behaviors.” BHT 1 stated if a patient was asleep “we (BHT) observe a rise and fall of the chest to ensure breathing.” BHT 1 stated that the importance of rounding was to ensure that patients were safe. During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed: -At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding was observed. -At 12:00 a.m., on 8/27/2025, no rounding was observed. -At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted -At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient. -At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients. -At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room. -At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed. -At 2:13 a.m., Patient 2 was seen going in and out of his room. -At 4:00 a.m., BHT 2 was not in his (BHT 2) chair in the hallway he (BHT 2) was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his (BHT 2) chair at 6:00 a.m. -At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed. During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no patient rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients’ door, check for patients’ breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 09/2022, the P&P indicated, “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ...” 2. During a review of Patient 2’s H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P indicated also Patient 2 had major depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable) and suicidal ideations (thoughts of taking one’s own life). During a review of Patient 2’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the roundings and observation form indicated Patient 2 was placed under standard observation and was on suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions. During a review of Patient 7’s H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/22/2025. The H&P also indicated Patient 7’s chief complaint was major depression with suicidal ideations with plan to overdose on fentanyl (pain killer medication). During a review of Patient 7’s document titled “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending 9/07/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient’s location and activity) and was on suicide/self-harm and fall precautions. During a review of Patient 16’s H&P, dated 8/28/2025, the H&P indicated Patient 16 was admitted to the facility on 8/28/2025. The H&P also indicated Patient 16 had psychosis (a mental health condition that causes a person to lose touch with reality), visual hallucination (sensory experiences of seeing things that are not actually present) and paranoid ideation (a pattern of thinking characterized by persistent and unfounded beliefs that one is being persecuted, harmed, or deceived). During a review of Patient 16’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 16 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 17’s H&P, dated 8/19/2025, the H&P indicated Patient 17 was admitted to the facility on 8/19/2025. The H&P also indicated Patient 17’s chief complaint was major depression with suicidal ideations and plan to hang self with blanket wrapped around neck. During a review of Patient 17’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 17 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 18’s H&P, dated 9/03/2025, the H&P indicated Patient 18 was admitted to the facility on 9/03/2025. The H&P indicated Patient 18’s chief complaint was paranoid delusion (a false belief that is firmly held despite clear evidence to the contrary), schizophrenia, depression with suicidal ideation to kill self with a knife. During a review of Patient 18’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 18 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 19’s H&P, dated 8/31/2025, the H&P indicated Patient 19 was admitted to the facility on 8/31/2025. The H&P indicated Patient 19 had chief complaint of depression and suicidal. During a review of Patient 19’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 19 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 20’s H&P, dated 9/02/2025, the H&P indicated Patient 20 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 20 was a danger to self, with Shizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and mood disorders, such as depression or mania [a state of abnormally elevated mood, energy, and activity that lasts for an extended period]) and anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease). During a review of Patient 20’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 20 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 21’s H&P, dated 9/02/2025, the H&P indicated Patient 21 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 21’s chief complaint was auditory hallucination (sensory experiences where a person hears sounds that are not present in the external environment) telling Patient 21 to kill self and suicidal ideation. During a review of Patient 21’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 21 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 22’s H&P, dated 1/29/2025, the H&P indicated Patient 22 was admitted to the facility on 1/30/2025. The H&P also indicated Patient 22’s chief complaint was schizophrenia and wanting to hurt others. During a review of Patient 22’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 22 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 23’s H&P, dated 9/05/2025, the H&P indicated Patient 23 was admitted to the facility on 9/05/2025. The H&P also indicated Patient 23’s chief complaint was depressive disorder and suicidal ideation with a plan to overdose with pills. During a review of Patient 23’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 23 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 24’s H&P, dated 9/01/2025, the H&P indicated Patient 24 was admitted to the facility on 9/01/2025. The H&P also indicated Patient 24’s chief complaint was gravely disabled (unable to take care of themselves) with homicidal ideation (thoughts of killing others) and wanting to hurt others. During a review of Patient 24’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 24 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 25’s H&P, dated 9/02/2025, the H&P indicated Patient 25 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 25’s chief complaint was depression and suicidal ideations with plan to jump in front of a car. During a review of Patient 25’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 25 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 26’s H&P, dated 8/20/2025, the H&P indicated Patient 26 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 26’s chief complaint was anxiety and suicidal ideations with a plan to walk into traffic. During a review of Patient 26’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 26 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 27’s H&P, dated 8/31/2025, the H&P indicated Patient 27 was admitted to the facility on 8/31/2025. The H&P also indicated Patient 27’s chief complaint was depression and suicidal ideation to kill self in any way. During a review of Patient 27’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 27 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 28’s H&P, dated 9/02/2025, the H&P indicated Patient 28 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 28 was gravely disabled with anxiety and hallucination, and positive for suicidal ideation. During a review of Patient 28’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 28 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 29’s H&P, dated 8/18/2025, the H&P indicated Patient 29 was admitted to the facility on 8/18/2025. The H&P also indicated Patient 29 was a danger to self with suicidal ideation and plan to overdose and run into traffic. During a review of Patient 29’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 29 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 30’s H&P, dated 9/02/2025, the H&P indicated Patient 30 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 30 was a danger to self and others and with positive suicidal ideation. During a review of Patient 30’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 30 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 31’s H&P, dated 9/06/2025, the H&P indicated Patient 31 was admitted to the facility on 9/06/2025. The H&P also indicated Patient 31’s chief complaint was schizophrenia, danger to self and others with positive suicidal ideation. During a review of Patient 31’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 31 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 32’s H&P, dated 8/29/2025, the H&P indicated Patient 32 was admitted to the facility on 8/29/2025. The H&P also indicated Patient 32’s chief complaint was schizophrenia, with positive suicidal ideation to hurt self by jumping in front of a van. During a review of Patient 32’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 32 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 33’s H&P, dated 9/04/2025, the H&P indicated Patient 33 was admitted to the facility on 9/04/2025. The H&P also indicated Patient 33’s chief complaint was depression with auditory hallucination to hurt self. During a review of Patient 33’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 33 was placed under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 34’s H&P, dated 9/03/2025, the H&P indicated Patient 34 was admitted to the facility on 9/03/2025. The H&P also indicated Patient 34’s chief complaint was major depressive disorder with substance abuse (harmful or excessive use of substances, such as alcohol, drugs, and medications), and danger to self and others. During a review of Patient 34’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 34 was placed under standard observation and was on suicide/self-harm and fall precautions. During a concurrent observation, interview and review of video footage on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the DBHU, the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The following was observed: - At 6:15 p.m. - No Behavioral Health Technician was observed making 15-minute rounds on patients in the (Behavioral Health Unit) BHU. - At 7:15 p.m. - No Behavioral Health Technician was observed making 15-minute rounds on patients in the BHU. - At 7:20 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening patient doors to check on patients. - At 7:34 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients. - At 8:04 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients. - At 8:19 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients. - At 8:34 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients. - At 8:44 p.m. - Licensed Vocational Nurse (LVN) 1 and BHT 4 sitting in chair with cell phone in hand. Observed watching their (LVN 1 and BHT 4) cell phone and not completing their 15-minute rounding on all patients assigned to make rounds on. - At 8:49 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients. - At 9:05 p.m. - LVN 1 sitting in chair and watching cell phone. BHT 5 observed not completing 15-minute rounding to all assigned patients. BHT 5 observed skipping 15-minute rounding, and observed opening, and closing patient doors quickly. - At 9:17 p.m. - BHT 5 observed not completing 15-minute rounding to all assigned patients. BHT 5 observed skipping 15-minute rounding, and observed opening, and closing patient doors quickly. During the same interview on 9/10/2025 at 2:16 p.m. with the DBHU, the DBHU confirmed the following: BHT and Nursing staff were not doing the assigned 15 minute rounding correctly for Patient 2, Patient 7, and Patients 16-34 on 9/06/2025 from 6 p.m. to 9:30 p.m. DBHU stated he (DBHU) would need to re-educate staff on Q 15-minute rounding process and to have staff perform a return demonstration to make sure they (the staff) understood how to correctly conduct a Q (every)15 minute rounding on patients. The DBHU further said that Staff needed to open patients’ room doors and go inside the patients’ rooms to check on patients (if patients are still breathing and not harming self or others). DBHU also said that it was a safety risk for patients when staff did not do proper rounding on patients. During a review of the facility’s “Behavioral Health Unit Roundings and Observation Form,” dated 9/06/2025 from 6 p.m. to 9 p.m., the document indicated Patient 2, Patient 7, and Patients 16-34 were monitored by BHT staff and LVN 1, every 15 minutes. However, the DBHU confirmed that the documentation was inaccurate, as it did not match what was observed in the video footage regarding patient rounds. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 09/2022, the P&P indicated, “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ...””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45743 Based on observation, interview, and record review, the facility failed to: 1. Ensure one (1) of 46 sampled patients (Patient 1) was free from all forms abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility’s policy on patient rights (a subset of human rights), when an allegation of sexual assault (an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent) was made by Patient 1 on 8/27/2025. This deficient practice had the potential for Patient 1 and other patients in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) to experience physical injury, psychological trauma, fear, or anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease), and may lose trust in healthcare providers and institutions. On 9/11/2025 at 1:30 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Nursing Officer (CNO), Quality of Risk Management coordinator (QRC), Quality Risk Management Director (QRMD) and the Manager of Risk and Regulatory. The facility failed to ensure the following: Ensure 15 sampled patients’ (Patients 1-15) location, behavior, and environmental or personal safety, were checked, in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) on 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., when an allegation of sexual assault (an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent) was made by Patient 1; When Registered Nurses in the behavioral health unit (BHU) were not observed conducting every 4 hour (Q4h) patient rounds (the process of regularly visiting patients to assess their condition) nor did they (RNs) ensure behavioral health technicians (BHT) performed patient rounds every 15 minutes, in accordance with the facility’s policy and procedure regarding patient rounding; Ensure proper rounding was conducted, by BHTs 4 and 5, for 21 sampled patients (Patient 2, Patient 16 -35), on 9/6/2025 from 6:00 p.m. to 9:30 p.m. These deficient practices resulted in all patients being inadequately monitored for eight (8) hours from 8/26/2025 at 11 p.m. to 7 a.m. on 8/27/2025 and three (3) hours on 9/6/2025 from 6 p.m. to 9 p.m., and had potentially placed patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death if not corrected. In addition, Patient 1 alleged being sexually assaulted by Patient 2 without the facility’s knowledge on when and how it happened. During a review of Patient 1’s “Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Progress Note,” dated 8/27/2025, the psychiatric progress note indicated, “This morning the patient (Patient 1) was anxious (feeling tense, on edge, restless, fearful), rambling at times, fixated on discharge (to go home). He (Patient 1) endorsed being sexually assaulted by his roommate (Patient 2), police department came to interview and Sexual Assault Response Team (SART, provides emotional support, advocacy, and access to victim assistance services) nurse made recommendations made by medical and nursing staff.” During a review of Patient 1’s “Progress Notes Report,” dated 8/27/2025, the record indicated Patient 1’s “Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person’s emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell).” The record further indicated at 8:53 a.m., on 8/27/2025, Patient 1 “Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night.” During an interview on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), the Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation for patient rounding, every 15 minutes, was for the staff to open the patients’ rooms’ door, check for patients’ breathing and ensure the patients were safe. DBHU also said that patient rounding was done for patient safety, and anything can occur if not done correctly. DBHU confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU stated BHTs were required to round every 15 minutes, while Charge Nurses (Registered Nurses, RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours. During a concurrent observation, interview and record review on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the DBHU, the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The video footage indicated inadequate rounding by BHT 4 who was seen standing by the patients’ door and not entering each of the patients’ rooms (Patient 2, Patient 16 -35). This observation was confirmed by the DBHU. During a review of the facility’s policy and procedure (P&P) titled, “Inpatient Rights and Responsibilities of Patients,” revised 08/2023, the P&P indicated “All personnel shall observe and respect these patient rights: 13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including government agencies of neglect or abuse.” During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 09/2022, the P&P indicated, “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ...” On 9/12/2025 at 4:59 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), CNO, Quality Risk Management Director, Quality of Risk Management Coordinator (QRC) and the Director of the Behavioral Health Unit (DBHU), after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews and record reviews. The acceptable IJ Removal Plan included the following: Enhanced round frequency where Charge Nurses/Resource Nurses were expected to round with the BHTs every top of the hour. Education on proper round procedures on the Behavioral Health Unit and Nursing leadership oversight began on 9/11/2025. Key points in the education included: Proper rounding of visual confirmation of patient and patient engagement, and a competency demonstration to verify proper rounding techniques. Staff members must complete education prior to their next scheduled BHU shift. Leadership oversight included: Hourly rounding conducted by the charge nurse to ensure rounds have been completed and documented by the BHTs will be done on each shift, the Director of Nursing (DON) reviewing both BHTs and Charge Nurses rounding logs. Other leadership interventions included the increase in the frequency of random spot checking of security footage. Findings: During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one’s own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (every 15 minutes) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions. During a review of Patient 1’s document titled, “Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form,” dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1’s behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m. During a review of Patient 1’s “Progress Notes Report,” dated 8/27/2025, the record indicated Patient 1’s “Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person’s emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell).” The record further indicated at 8:53 a.m., Patient 1 “Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night.” During a review of Patient 1’s “Progress Note,” dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1’s family) verbalized understanding of discharge instructions. During a review of Patient 2’s H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations. During a review of Patient 2’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient’s location and activity) and was on suicide/self-harm and fall precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious. During a review of Patient 2’s “Psychiatric Discharge Note,” dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025. During a review of Patients’ 1-15’s document titled, “BHU Q (every) 15 Minute Roundings and Observation Form,” dated 8/26/2025, the form indicated from times 2300 (11:00 p.m.) to 0700 (7:00 a.m.), Patients’ 1-15’s behavior was documented asleep/breathing. During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated “we (BHT) observe patients every 15 minutes (q15), and check for patient breathing, location and patients’ behaviors.” BHT 1 stated if a patient was asleep “we (BHT) observe a rise and fall of the chest to ensure breathing.” BHT 1 stated that the importance of rounding was to ensure that patients were safe. During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed: -At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting patients to assess their condition) was observed. -At 12:00 a.m., on 8/27/2025, no rounding was observed. -At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted -At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient. -At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients. -At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room. -At 2:00 a.m., BHT 3 was seen sitting in chair in the hallway and no rounding was completed. -At 2:13 a.m., Patient 2 was seen going in and out of his room. -At 4:00 a.m., BHT 2 was not in his (BHT 2) chair in the hallway he (BHT 2) was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m. -At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed. During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients’ door, check for patients’ breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (Registered Nurses, RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs [Licensed Vocational Nurses]) every 2 hours. During an interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1’s and BHT 2’s Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). The DBHU said he (DBHU) asked the charge nurses to make sure rounding was being done on time. The DBHU stated he (DBHU) requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding. During the same interview on 9/11/2025 at 10:07 a.m. with the DBHU, the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault (an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent) made by Patient 1’s significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. The DBHU stated that Patient 1 repeatedly verbalized “I just want to go home.” During a record review of the facility’s documents titled, “Inservice Roster: Topic Rounding, Observation and Monitoring of Patients,” dated 8/28/2025, 8/29/2025-8/30/2025 and 9/9/2025, the in-service roster indicated that 68 out of a total of 131 Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff members had been in-serviced regarding the BHU’s policy titled, “Rounding, Observation, and Monitoring of Patients.” During a record review of the facility’s document titled, “Behavioral Health Unit staffing sheet” dated 9/10/2025, the document indicated the following: -For the 7AM to 7PM shift, a total of 10 out of 14 BHU staff members have attended the in-service regarding patient rounding. -For the 7PM to 7AM shift, a total of 5 out of 19 BHU staff members have attended the in-service regarding patient rounding. During an interview on 9/9/2025 at 3:57 p.m. with the DBHU, the DBHU stated that in-service training for patient rounding was still on going and not all BHU staff have completed the in-service. The DBHU stated that the goal was to have all staff in-serviced as soon as possible. During an interview on 9/11/2025 at 9 a.m. with the Quality Risk Management Director (QRMD), the QRMD stated the following: The facility provided in-service training, on 8/28/2025, for patient rounding every 15 minutes, after the first CDPH (California Department of Public Health, a regulatory agency) surveyor initially investigated the allegation of sexual abuse made by Patient 1 on 8/27/2025. The QRMD stated the night shift staff were not conducting their rounds every 15 minutes. The QRMD also stated that even though training on patient rounding had been provided, staff were still not conducting the patient rounds properly. During a review of the facility’s policy and procedure (P&P) titled, “Inpatient Rights and Responsibilities of Patients” revised 08/2023, the P&P indicated “All personnel shall observe and respect these patient rights: 13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including government agencies of neglect or abuse.” During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 9/2022, the P&P indicated, “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50516 Based on observation, interview and record review, the facility failed to: 1. Ensure adequate supervision of the facility’s Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff that included Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and the Behavioral health Technicians (BHTs), to ensure consistent and accurate Q (every) 15-minute patient rounding (the process of regularly visiting patients to assess their condition) for 15 of 46 sampled patients (Patients 1-15), in accordance with the facility’s policy regarding “Rounding, Observation, and Monitoring of Patients.” This deficient practice had the potential to place patients at risk for suicide (thoughts of taking one’s own life), self-harm, assault (an intentional act that causes a reasonable fear of immediate harmful or offensive contact, even if no physical contact actually occurs), or undetected medical emergencies, by leaving patients unsupervised for extended periods. 2. Ensure nursing staff adequately assessed a patient’s care needs and addressed, in a timely manner, one of 46 sampled patient’s (Patient 39) low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs), by calling for a Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration), in accordance with the facility’s policy regarding calling a RRT and policy on Standards of Nursing Practice pertaining to the nursing care process. Patient 39 had a persistently low blood pressure for over 3 hours in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), on 5/26/2025, before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries). This deficient practice resulted in Patient 39 having a delay in further evaluation and treatment, when Patient 39 remained in the Telemetry unit for more than three hours before being transferred to the Intensive Care Unit (ICU), which could have led to further complications and/or death. Findings: 1. During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one’s own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (every 15 minutes) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions. During a review of Patient 1’s document titled, “Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form,” dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1’s behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m. During a review of Patient 1’s “Progress Notes Report,” dated 8/27/2025, the record indicated Patient 1’s “Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person’s emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell).” The record further indicated at 8:53 a.m., Patient 1 “Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night.” During a review of Patient 1’s “Progress Note,” dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1’s family) verbalized understanding of discharge instructions. During a review of Patient 2’s H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations. During a review of Patient 2’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient’s location and activity) and was on suicide/self-harm and fall precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious. During a review of Patient 2’s “Psychiatric Discharge Note,” dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025. During a review of Patient 3’s H&P, dated 8/25/2025, the H&P indicated Patient 3 was admitted to the facility on 8/25/2025. The H&P also indicated Patient 3 had depression with suicidal ideations. During a review of Patient 3’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 3 was on standard observation and was on suicide/self-harm and fall precautions (a set of preventive measures to prevent patient injuries, such as bruises, fractures [broken bones], and even death, by reducing the frequency and severity of falls). During a review of Patient 4’s H&P, dated 8/25/2025, the H&P indicated Patient 4 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 4 was on a 5150 (72-hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal and homicidal ideations (thoughts of killing others). The H&P indicated Patient 4 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 4’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 at 8 a.m. and 12 p.m., the document indicated Patient 4 was hopeless/helpless and socially withdrawn. On 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., Patient 4 was in a depressed mood. During a review of Patient 5’s H&P, dated 8/24/2025, the H&P indicated Patient 5 was admitted to the facility on 8/23/2025 for schizophrenia (person loses touch with reality, experiencing things like false beliefs [delusions], seeing or hearing things that aren’t there [hallucinations]), disorganized thinking and speech, and withdrawal from others. The H&P indicated Patient 5 was placed on a 5150 hold for being a danger to others and hearing voices. During a review of Patient 5’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 5 was on standard observation and on suicide/self-harm and fall precautions. During a review of Patient 6’s H&P, dated 8/24/2025, the H&P indicated Patient 6 was admitted to the facility on 8/23/2025 for anxiety. The H&P also indicated Patient 6 had a chief complaint of being a danger to others and mental breakdown. During a review of Patient 6’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025, the H&P indicated that on 8/26/2025, Patient 6 was placed under 1:1 (healthcare individual stays with the patient as a safety precaution) Arms-Length observation (a staff member remains within arm’s reach of the patient at all times, providing immediate intervention and care, especially when a patient poses a risk to themselves or others due to mental distress or health concerns) until 2:01 p.m. On 8/26/2025 at 2:01 p.m., Patient 6 was placed under Line of Sight (direct view of patient) observation. On 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., Patient 6 was on suicide/self-harm and fall precautions. The roundings and observation form further indicated that on 8/26/2025, Patient 6 was anxious at 9:30 a.m., 9:45 a.m., 11 a.m., 11:15 a.m., and 12:45 p.m. In addition, Patient 6 was agitated (feelings of restlessness and irritability) and hostile at 8 a.m. and also hostile at 12 p.m. on 8/26/2025. During a review of Patient 7’s H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 7’s chief complaint was major depression with suicide ideations with plan to overdose on fentanyl (pain killer medication). During a review of Patient 7’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 8’s H&P, dated 8/22/2025, the H&P indicated Patient 8 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 8 presented with suicidal ideations and major depressive disorder. During a review of Patient 8’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 8 was placed under standard observation and on suicide/self-harm precautions. During a review of Patient 9’s H&P, dated 8/22/2025, the H&P indicated Patient 9 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 9 presented with suicidal ideations with plan to overdose. During a review of Patient 9’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 9 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 10’s H&P, dated 8/21/2025, the H&P indicated Patient 10 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 10 had depression. During a review of Patient 10’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 10 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 11’s H&P, dated 8/21/2025, the H&P indicated Patient 11 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 11 had suicidal ideations and had a history of schizoaffective disorder (impaired ability to distinguish reality from what is not real). During a review of Patient 11’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 11 was placed under standard observation and on suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 11’s behavior was intrusive (actions or thoughts that are unwanted, distressing, and often repetitive) at 7:45 a.m., 8 a.m., 8:15 a.m., and 8:30 a.m. on 8/27/2025. During a review of Patient 12’s H&P, dated 8/22/2025, the H&P indicated Patient 12 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 12 was brought by an outside acute care hospital (a healthcare facility that provides short-term, intensive medical and surgical care for patients with acute illnesses or injuries) with complaints of “hurting others with a plan to shoot them.” During a review of Patient 12’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 12 was under standard observation and under suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 12 was agitated on 8/26/2025 at 8 a.m., and anxious at 8:15 a.m. and 9:15 a.m. on 8/26/2025. During a review of Patient 13’s H&P, dated 8/21/2025, the H&P indicated Patient 13 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 13 was gravely disabled (unable to take care of themselves) and a danger to others. During a review of Patient 13’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 13 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 14’s H&P, dated 8/20/2025, the H&P indicated Patient 14 was admitted to the facility on 8/20/2025. The H&P further indicated Patient 14 had suicidal ideations. During a review of Patient 14’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 14 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 15’s H&P, dated 8/22/2025, the H&P indicated Patient 15 was admitted to the facility on 8/19/2025. The H&P further indicated Patient 15 had suicidal ideations and a history of schizophrenia. During a review of Patient 15’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the roundings and observation form indicated Patient 15 was under standard observation and on suicide/self-harm and fall precautions. During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated “we (BHT) observe patients every 15 minutes (Q 15), and check for patients’ breathing, location and patients’ behaviors.” BHT 1 stated if a patient was asleep “we (BHT) observe a rise and fall of the chest to ensure breathing.” BHT 1 stated that the importance of rounding was to ensure that patients were safe. During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed: -At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed. -At 12:00 a.m., on 8/27/2025, no rounding was observed. -At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted -At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient. -At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients. -At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room. -At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed. -At 2:13 a.m., Patient 2 was seen going in and out of his room. -At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m. -At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed. During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted, every 15 minutes, was for the staff to open the patients’ door, check for patients’ breathing and ensure the patients were safe. DBHU said that patient rounding was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours. During an interview on 9/12/2025 at 4:30 p.m. with Registered Nurse (RN) 3, RN 3 stated Charge Nurses have oversight of the staff, especially BHTs. RN 3 also stated that all staff have responsibility in ensuring patient safety by conducting proper patient rounding. During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 09/2022, the P&P indicated, “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ...” During a review of the facility’s document titled, “Position Description: Behavioral Health Technician,” dated 7/2024, the document indicated The Behavioral Health Technician supports licensed staff in providing safe and therapeutic patient care as delegated and in adherence to policies and procedures. The document also indicated that Essential Functions included observing and monitoring patients’ progress and reports observations to appropriate staff. 2. During a review of Patient 39 ’ s “History and Physical (H&P),” dated 5/25/2025, the H&P indicated Patient 39 was admitted to the facility ’ s telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm) for altered mental status (different level of thinking, communicating, than what is normal for someone). Patient 39 ’ s medical history included stroke (loss of blood flow to a part of the brain) and pseudo (fake) - seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness [loss of awareness of oneself and the surroundings due to a temporary reduction in blood flow to the brain]). During a review of Patient 39 ’ s “Intensivist Consult Note,” dated 5/27/2025, the record indicated Patient 39 was admitted to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for hypotension (low blood pressure below the normal range of 120/90 millimeters of mercury [mmHg, a unit of measurement]). The note further indicated Patient 39 ’ s “Condition was further complicated when she received all her (Patient 39) home medications, including antipsychotics (medications used to treat and manage mental health conditions) and antihypertensives (medications used to lower and control blood pressure), at one time. Subsequently, she Patient 39) became hypotensive with blood pressure dropping into the sixties. Treatment was initiated with intravenous (IV, into the vein) fluid resuscitation (to bring up) and a Levophed (Norepinephrine, medication used to raise blood pressure) infusion. The patient is currently improving with these interventions.” During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and the Clinical Analyst Information Technology (CAIT), Patient 39 ’ s “Daily Focus Assessment Report,” dated 5/26/2025, was reviewed. The report indicated at 8:00 a.m. on 5/26/2025, Patient 39 was “Awake/Alert, Oriented to Person, Time, Place, and Situation, Spontaneous Eye Opening, Appropriate Verbal Response, Obeys Commands, Clear Speech ...Glasgow Coma Scale (GCS, level of awareness with a maximum level of 15 indicating full awareness) 15/15.” RN 12 and the CAIT confirmed that at at 9:00 p.m., Patient 39 was “Lethargic (slow to respond), nonverbal” and had a GCS score of 4/15 for “Eyes to painful stimuli, verbal: none, motor: none.” During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39 ’ s “Vitals (Vital Signs, include temperature, heart rate, respiratory rate, blood pressure) Inquiry,” dated 5/26/2025, was reviewed. The record indicated the following on 5/26/2025: -At 4:45 p.m., Patient 39 ’ s Blood Pressure (BP) was 85/46 (Normal is 120/90 millimeters of mercury [mmHg, a unit of measurement) in the telemetry unit; -At 6:01 p.m., Patient 39 ’ s BP was 89/44 -At 7:00 p.m., Patient 39 ’ s BP was 90/50 -At 7:27 p.m., Patient 39 ’ s BP was 61/38 -At 7:43 p.m., Patient 39 ’ s BP was 89/44 -At 7:46 p.m., Patient 39 ’ s BP was 126/107 -At 7:57 p.m., Patient 39 ’ s BP was 87/34 -At 7:58 p.m., Patient 39 ’ s BP was 77/40 -At 8:22 p.m., Patient 39 ’ s BP was 54/33 -At 9:00 p.m., Patient 39 ’ s BP was 72/38 in the ICU -At 9:05 p.m., Patient 39 ’ s BP was 80/59, and at 9:15 p.m. increased to 155/98. During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39 ’ s “Progress Notes Report,” dated 5/26/2025, was reviewed. The report indicated at 5:30 p.m. on 5/26/2025, Patient 39 ’ s BP was 90/55 (taken more than half an hour after the first low BP reading from 4:45 p.m.). Another entry at 8:05 p.m. indicated Patient 39 ’ s “fluid challenge (Normal saline, fluids that go into the vein to balance the body ’ s fluids and help with blood pressure given) and Albumin (medication used to help raise blood pressure) unsuccessful. Pt (Patient 39) is arousable (to be able to be stimulated, awakened, or excited from a state of sleep, unconsciousness, or a lack of response), but drowsy (feel sleepy and sluggish). Endorsed to (name of RN) night shift RN.” A later entry at 8:17 p.m. indicated at 8:15 p.m., Patient 39 ’ s BP was 74/44, and “MD (medical doctor) ordered to transfer patient to ICU ...patient transferred.” During further concurrent interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and the Clinical Analyst IT (CAIT), Patient 39 ’ s “Medication Administration Record (MAR),” dated 5/26/2025, was reviewed. The MAR indicated Patient 39 received Albumin (medication used to raise blood pressure) and two liters (a unit of measure) of Normal Saline in the telemetry unit. The MAR further indicated Patient 39 received Norepinephrine (Levophed, IV medication used to raise blood pressure and requires close monitoring) in the ICU after being transferred from the Telemetry unit. During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39 ’ s “Electronic Medical Record,” undated, was reviewed. CAIT confirmed that Patient 39 was transferred to the Intensive Care Unit (ICU, where patients are closely monitored) on 5/26/2025 at 8:28 p.m. CAIT also confirmed that Patient 39 remained in the telemetry unit, with low blood pressure, for over three hours prior to being transferred to the ICU. During the same interview on 9/11/2025 at 3:26 p.m. with RN 12, RN 12 stated RRT would be called when there was a change in a patient ’ s status (condition) or BP, and anyone can call for a RRT. RN 12 also stated she (RN 12) thought it would have been appropriate to have called a rapid response for Patient 39. During an interview on 9/12/2025 at 2:09 p.m. with the Chief Nursing Officer (CNO), the CNO stated, “Nurses can call (RRT) if they need assistance and there ’ s no harm to call a rapid response.” CNO also stated, “The purpose of a rapid response was to get interventions to help the patient.” During a review of the facility ’ s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated 7/2022, the P&P indicated, “It is the policy of (name of facility) to provide all patients with a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process.The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse ’ s decision-making.” During a review of the facility ’ s policy and procedure (P&P) titled “Rapid Response Team (RRT),” dated 12/2014, the P&P indicated: “Purpose: To improve patient outcomes by providing expert assessment, early intervention and stabilization for patients and to prevent clinical deterioration and/or arrest. Philosophy: A. The Rapid Response Team (RRT) shall be used to create a culture where hospital staff, especially nurses, are encouraged to ask for help if they are uncertain about a patient ’ s condition or desired intervention. B. The Team is also a vehicle to enhance the knowledge and assessment skills of front-line staff and helps to create a supportive environment. Policy: C. Criteria for calling the Team may include but are not limited to one or more of the following ...Changes in SBP (<90 mmHg) ...Acute mental status change ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42976 Based on observation, interview, and record review, the facility failed to: 1. Ensure nursing staff adhered to the facility’s policy and procedure regarding “Rounding, Observation and Monitoring of Patients,” and the facility’s charting/documentation policy, when staff did not perform and accurately document the Q (every) 15-minute rounding (observing patient location and behavior), for 15 of 46 sampled patients (Patients 1-15), from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m. This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person’s consent) by Patient 2 without the facility’s knowledge on when and how it happened. 2. Ensure a concern of low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs) lasting over several hours (3 hours), for one of 46 sampled patients (Patient 39), was escalated by using a Rapid Response Team (RRT, group of individuals [may include a nurse, respiratory therapist, physician] that responds to concerning or emergency situations and can provide additional evaluations and interventions), in accordance with the facility’s policy and procedure regarding “Rapid Response Team (RRT).” This deficient practice resulted in Patient 39, remaining in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), with persistent low blood pressure for more than three hours, before being transferred to a higher level of care (a more intensive and comprehensive level of medical health treatment), which delayed treatment and could have worsened Patient 39’s condition. 3. Ensure an Oxygen Tank (a device to provide respiratory [to breathe] support) was stored and readily available for immediate use on one of two sampled crash carts (Cart #1, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment), in the Emergency Department (ED, a specialized hospital unit that provides 24/7 unscheduled medical care for acute [sudden in onset], severe, and life-threatening injuries and illnesses), which may impact 46 of 46 sampled patients, in accordance with the facility’s policy regarding crash cart equipment and medications. This deficient practice had the potential to result in endangering patients’ life by delaying the ability to provide respiratory support (medical interventions that assist a patient’s breathing when they are unable to do so adequately on their own. Example: providing oxygen therapy from an oxygen tank) in an emergency, which may result in patient harm and/or death. 4. Ensure staff followed the facility’s “Peripheral Inserted Central Catheter: Assisting, Insertion, Care and Removal Policy,” for 2 of 46 sampled patients (Patient 44 and Patient 45), when staff did not provide proper PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large, significant vein responsible for returning deoxygenated blood collected from the body to the heart], and used for intravenous treatment that is required over a long period) care by not changing Patient 44’s soiled PICC line dressing and not properly securing Patient 45’s PICC line with a securement device. This deficient practice had the potential for Patient 44 and Patient 45 to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper maintenance and care of PICC line. Findings: 1. During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one’s own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient’s location and activity) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions. During a review of Patient 1’s document titled, “Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form,” dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1’s behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m. During a review of Patient 1’s “Progress Notes Report,” dated 8/27/2025, the record indicated Patient 1’s “Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person’s emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell).” The record further indicated at 8:53 a.m., Patient 1 “Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night.” During a review of Patient 1 “Progress Note” dated 8/28/2025 and timed at 11:20 a.m., the record indicated was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1’s family) verbalized understanding of discharge instructions. During a review of Patient 2’s H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations. During a review of Patient 2’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard and was on suicide/self-harm and fall precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious. During a review of Patient 2’s “Psychiatric Discharge Note,” dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025. During a review of Patient 3’s H&P, dated 8/25/2025, the H&P indicated Patient 3 was admitted to the facility on 8/25/2025. The H&P also indicated Patient 3 had depression with suicidal ideations. During a review of Patient 3’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 3 was on standard observation and was on suicide/self-harm and fall precautions (a set of preventive measures to prevent patient injuries, such as bruises, fractures [broken bones], and even death, by reducing the frequency and severity of falls). During a review of Patient 4’s H&P, dated 8/25/2025, the H&P indicated Patient 4 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 4 was on a 5150 (72-hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal and homicidal ideations (thoughts of killing others). The H&P indicated Patient 4 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 4’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 at 8 a.m. and 12 p.m., the document indicated Patient 4 was hopeless/helpless and socially withdrawn. On 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., Patient 4 was in a depressed mood. During a review of Patient 5’s H&P, dated 8/24/2025, the H&P indicated Patient 5 was admitted to the facility on 8/23/2025 for schizophrenia (person loses touch with reality, experiencing things like false beliefs [delusions], seeing or hearing things that aren’t there [hallucinations]), disorganized thinking and speech, and withdrawal from others. The H&P indicated Patient 5 was placed on a 5150 hold for being a danger to others and hearing voices. During a review of Patient 5’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 5 was on standard observation and on suicide/self-harm and fall precautions. During a review of Patient 6’s H&P, dated 8/24/2025, the H&P indicated Patient 6 was admitted to the facility on 8/23/2025 for anxiety. The H&P also indicated Patient 6 had a chief complaint of being a danger to others and mental breakdown. During a review of Patient 6’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025, the H&P indicated that on 8/26/2025, Patient 6 was placed under 1:1 (healthcare individual stays with the patient as a safety precaution) Arms-Length observation until 2:01 p.m. On 8/26/2025 at 2:01 p.m., Patient 6 was placed under Line of Sight (direct view of patient) observation. On 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., Patient 6 was on suicide/self-harm and fall precautions. The roundings and observation form further indicated that on 8/26/2025, Patient 6 was anxious at 9:30 a.m., 9:45 a.m., 11 a.m., 11:15 a.m., and 12:45 p.m. In addition, Patient 6 was agitated (feelings of restlessness and irritability) and hostile at 8 a.m. and was hostile at 12 p.m. on 8/26/2025. During a review of Patient 7’s H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 7’s chief complaint was major depression with suicide ideations with plan to overdose on fentanyl (pain killer medication). During a review of Patient 7’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation and was on suicide/self-harm and fall precautions. During a review of Patient 8’s H&P, dated 8/22/2025, the H&P indicated Patient 8 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 8 presented with suicidal ideations and major depressive disorder. During a review of Patient 8’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 8 was placed under standard observation and on suicide/self-harm precautions. During a review of Patient 9’s H&P, dated 8/22/2025, the H&P indicated Patient 9 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 9 presented with suicidal ideations with plan to overdose. During a review of Patient 9’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 9 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 10’s H&P, dated 8/21/2025, the H&P indicated Patient 10 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 10 had depression. During a review of Patient 10’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 10 was placed under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 11’s H&P, dated 8/21/2025, the H&P indicated Patient 11 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 11 had suicidal ideations and had a history of schizoaffective disorder (impaired ability to distinguish reality from what is not real). During a review of Patient 11’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 11 was placed under standard observation and on suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 11’s behavior was intrusive (actions or thoughts that are unwanted, distressing, and often repetitive) at 7:45 a.m., 8 a.m., 8:15 a.m., and 8:30 a.m. on 8/27/2025. During a review of Patient 12’s H&P, dated 8/22/2025, the H&P indicated Patient 12 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 12 was brought by an outside acute care hospital (a healthcare facility that provides short-term, intensive medical and surgical care for patients with acute illnesses or injuries) with complaints of “hurting others with a plan to shoot them.” During a review of Patient 12’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 12 was under standard observation and under suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 12 was agitated on 8/26/2025 at 8 a.m., and anxious at 8:15 a.m. and 9:15 a.m. on 8/26/2025. During a review of Patient 13’s H&P, dated 8/21/2025, the H&P indicated Patient 13 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 13 was gravely disabled (unable to take care of themselves) and a danger to others. During a review of Patient 13’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 13 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 14’s H&P, dated 8/20/2025, the H&P indicated Patient 14 was admitted to the facility on 8/20/2025. The H&P further indicated Patient 14 had suicidal ideations. During a review of Patient 14’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 14 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patient 15’s H&P, dated 8/22/2025, the H&P indicated Patient 15 was admitted to the facility on 8/19/2025. The H&P further indicated Patient 15 had suicidal ideations and a history of schizophrenia. During a review of Patient 15’s document titled, “Behavioral Health Unit Roundings and Observation Form,” dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the roundings and observation form indicated Patient 15 was under standard observation and on suicide/self-harm and fall precautions. During a review of Patients 1-15 document titled “BHU Q15 Minute Roundings and Observation Form” dated 8/26/2025 indicated from times 2300 (11:00 p.m.) to 0700 (7:00 a.m.) Patients 1-15 behavior was asleep/breathing (AB). During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated “we (BHT) observe patients every 15 minutes (q15), and check for patients’ breathing, location and patients’ behaviors.” BHT 1 stated if a patient was asleep “we (BHT) observe a rise and fall of the chest to ensure breathing.” BHT 1 stated that the importance of rounding was to ensure that patients were safe. During a concurrent observation, interview and video footage review o on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed: -At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed. -At 12:00 a.m., on 8/27/2025, no rounding was observed. -At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted -At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient. -At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients. -At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room. -At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed. -At 2:13 a.m., Patient 2 was seen going in and out of his room. -At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m. -At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed. During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients’ door, check for patients’ breathing and ensure the patients were safe. DBHU said that patient rounding was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours. DBHU also confirmed that staff were falsifying documentation of patient rounding. During an interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1’s and BHT 2’s Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1’s and BHT 2’s Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). The DBHU said he (DBHU) asked the charge nurses to make sure rounding was being done on time. The DBHU also said he (DBHU) requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding. During the same interview on 9/11/2025 at 10:07 a.m., the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault made by Patient 1’s significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. The DBHU stated that Patient 1 repeatedly verbalized “I just want to go home.” During a review of the facility’s policy and procedure (P&P) titled, “Rounding, Observation and Monitoring of Patients,” dated 09/2022, the P&P indicated, “It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient’s whereabouts and ensure a safe environment. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ...” During a review of the facility’s policy and procedure (P&P) titled, “Documentation (Charting) Policy,” revised 07/2022, the P&P indicated the following: Purpose: To provide a concise, complete and accurate record of treatments, symptoms and observation to assist physicians in diagnosing and prescribing, assist nurses and ancillary departments in planning care and to maintain a legal record ...Procedure: 2. All charting must be complete and accurate. 2. During a review of Patient 39’s “History and Physical (H&P),” dated 5/25/2025, the H&P indicated Patient 39 was admitted to the facility’s telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm) for altered mental status (different level of thinking, communicating, than what is normal for someone). Patient 39’s medical history included stroke (loss of blood flow to a part of the brain) and pseudo (fake) - seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness [loss of awareness of oneself and the surroundings due to a temporary reduction in blood flow to the brain]). During a review of Patient 39’s “Intensivist Consult Note,” dated 5/27/2025, the record indicated Patient 39 was admitted to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for hypotension (low blood pressure below the normal range of 120/90 millimeters of mercury [mmHg, a unit of measurement]). The note further indicated Patient 39’s “Condition was further complicated when she received all her (Patient 39) home medications, including antipsychotics (medications used to treat and manage mental health conditions) and antihypertensives (medications used to lower and control blood pressure), at one time. Subsequently, she (Patient 39) became hypotensive with blood pressure dropping into the sixties. Treatment was initiated with intravenous (IV, into the vein) fluid resuscitation (to bring up) and a Levophed (Norepinephrine, medication used to raise blood pressure) infusion. The patient (Patient 39) is currently improving with these interventions.” During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and the Clinical Analyst Information Technology (CAIT), Patient 39’s “Daily Focus Assessment Report,” dated 5/26/2025, was reviewed. The record indicated at 8:00 a.m. on 5/26/2025, Patient 39 was “Awake/Alert, Oriented to Person, Time, Place, and Situation, Spontaneous Eye Opening, Appropriate Verbal Response, Obeys Commands, Clear Speech ...Glasgow Coma Scale (GCS, level of awareness with a maximum level of 15 indicating full awareness) 15/15.” RN 12 and the CAIT said that at 9:00 p.m., Patient 39 was “Lethargic (slow to respond), nonverbal” and had a GCS score of 4/15 for “Eyes to painful stimuli, verbal: none, motor: none.” During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39’s “Vitals (Vital Signs, includes temperature, heart rate, respiratory rate, blood pressure) Inquiry,” dated 5/26/2025, was reviewed. The record indicated the following on 5/26/2025: -At 4:45 p.m., Patient 39’s Blood Pressure (BP) was 85/46 (normal: 120/90 millimeters of mercury [mmHg, a unit of measurement]) in the telemetry unit; -At 6:01 p.m., Patient 39’s BP was 89/44 -At 7:00 p.m., Patient 39’s BP was 90/50 -At 7:27 p.m., Patient 39’s BP was 61/38 -At 7:43 p.m., Patient 39’s BP was 89/44 -At 7:46 p.m., Patient 39’s BP was 126/107 -At 7:57 p.m., Patient 39’s BP was 87/34 -At 7:58 p.m., Patient 39’s BP was 77/40 -At 8:22 p.m., Patient 39’s BP was 54/33 -At 9:00 p.m., Patient 39’s BP was 72/38 in the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) -At 9:05 p.m., Patient 39’s BP was 80/59, and at 9:15 p.m. increased to 155/98 in the ICU. During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39’s “Progress Notes Report,” dated 5/26/2025, was reviewed. The report indicated that at 5:30 p.m. on 5/26/2025, Patient 39’s BP was 90/55 (taken more than half an hour after the first low BP reading from 4:45 p.m.). Another entry at 8:05 p.m. indicated Patient 39’s “fluid challenge (Normal saline, fluids that go into the vein to balance the body’s fluids and help with blood pressure given) and Albumin (medication used to help raise blood pressure) unsuccessful. Pt (Patient 39) is arousable (to be able to be stimulated, awakened, or excited from a state of sleep, unconsciousness, or a lack of response), but drowsy (feel sleepy and sluggish). Endorsed to (name of RN) night shift RN.” A later entry at 8:17 p.m. indicated at 8:15 p.m., Patient 39’s BP was 74/44, “MD ordered to transfer patient to ICU ...patient transferred.” During further interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and Clinical Analyst IT (CAIT), Patient 39’s “Medication Administration Record,” undated, was reviewed. The record indicated the following: -On 5/26/2025 at 6:30 p.m. and at 7:18 p.m., Patient 39 received one liter (a unit of measure) of Normal Saline (a total of two liters) in the telemetry unit. -On 5/26/2025 at 7:44 p.m., Patient 39 received Albumin (medication used to help balance the body’s fluid levels and blood pressure) in the telemetry unit. -On 5/26/2025 at 9:30 p.m., Patient 39 received Norepinephrine (medication that goes into the vein to raise blood pressure) in the ICU. During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39’s “Electronic Medical Record,” undated, was reviewed. CAIT confirmed Patient 39 was transferred to the Intensive Care Unit on 5/26/2025 at 8:28 p.m from the telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm). CAIT also confirmed Patient 39 remained in the Telemetry floor with low blood pressure for over three hours prior to being transferred to ICU. During the same interview on 9/11/2025 at 3:26 p.m. with RN 12, RN 12 stated RRT would be called when there was a change in a patient’s status (condition) or BP, and anyone can also call for a RRT. RN 12 further stated she (RN 12) thought it would have been appropriate for staff to have called a rapid response for Patient 39 on 5/26/2025. During an interview on 9/12/2025 at 2:09 p.m. with the Chief Nursing Officer (CNO), the CNO stated, “Nurses can call if they need assistance and there’s no harm to call a rapid response.” CNO also stated, “The purpose of a rapid response was to get interventions to help the patient.” During a review of the facility’s policy and procedure (P&P) titled, “Rapid Response Team (RRT),” dated 12/2014, the P&P indicated the following: “Purpose: To improve patient outcomes by providing expert assessment, early intervention and stabilization for patients and to prevent clinical deterioration and/or arrest (cardiac or respiratory arrest [when the heart stops beating or when the patient stops breathing]). Philosophy: A. The Rapid Response Team (RRT) shall be used to create a culture where hospital staff, especially nurses, are encouraged to ask for help if they are uncertain about a patient’s condition or desired intervention. B. The Team is also a vehicle to enhance the knowledge and assessment skills of front-line staff and helps to create a supportive environment. Policy: C. Criteria for calling the Team may include but are not limited to one or more of the following ...Changes in SBP (<90 mmHg) ...Acute mental status change ...” 3. During a concurrent observation and interview on 9/9/2025 at 10:54 a.m. with the Emergency Room Director (ER/ICUD), in the emergency room department, one of two crash carts (crash cart #1, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment) was missing an oxygen tank (O2). This observation was confirmed by the ER/ICUD. The ER/ICUD also stated that the O2 tank should be with the crash cart and should be readily available for use in case of an emergency. The ER/ICUD further stated that Charge Nurses were responsible for checking the crash cart every shift and use the crash cart checklist as guidance and if there was a missing item (such as a full oxygen tank), then the missing item should be replaced. During a review of the facility’s policy and procedure (P&P) titled, “Crash Cart Equipment and Medications,” revised 02/2024, the P&P indicated, “Emergency carts and external equipment are to be checked a minimum of once each calendar day by the Charge Nurse or assigned licensed nurse ...Check for: O2 Cylinder present and at 1,000 psi or greater.” 4.a. During a review of Patient 44’s “Face Sheet (a document that summarizes a patient’s essential medical information in a concise and easy-to-read format),” dated 9/06/2025, the Face Sheet indicated Patient 44 was admitted to the facility unit on 9/06/2025 at 14:13 (2:13 p.m.) p.m. During a review of Patient 44’s “History and Physical (H&P),” dated 9/06/2025, the “H&P” indicated the following: Patient 44 with a history of Tachycardia (abnormal fast heartbeats), Dementia (a general term for a group of conditions that cause a gradual decline in memory, thinking, reasoning, and language), Pulmonary Edema (condition where excess fluid accumulates in the lungs, making it difficult to breathe), and Code Blue (signals a life-threatening medical emergency, typically cardiac [the heart stops beating] or respiratory arrest [patient stops breathing], requiring immediate resuscitation [to revive] from a specially trained medical team). During a review of Patient 44’s PICC (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large, significant vein responsible for returning deoxygenated blood collected from the body to the heart], and used for intravenous treatment that is required over a long period) Insertion Documentation, dated 9/7/2025, the “PICC Insertion Documentation” indicated the following: Patient 44 had a PICC line inserted to the left upper arm. During a concurrent observation and interview on 9/09/2025 at 10:27 a.m., with Charge Nurse (CN 2) and Registered Nurse (RN 1), in Patient 44’s room, Patient 44 had a PICC line to the left upper arm with transparent dressing soiled with blood, covering the insertion site and unable to see through the dressing. RN 1 stated the following: She (RN 1) did not assess the PICC line dressing today (9/9/2025) and did not know if she (RN 1) should change the dressing. CN 2 stated the following: Patient 44’s PICC line dressing should be changed, and the PICC line dressing should not be bloody. CN 2 stated the soiled dressing remaining in place was a risk for infection for Patient 44. During an interview on 9/12/2025 at 10:58 a.m. with the Intensive Care Unit Director (ICUD 1), ICUD 1 stated the following: Confirmed RN 1 did not provide proper PICC line maintenance care for Patient 44. RN 1 did not change PICC line dressing that was soiled, which was a risk for infection. During a review of the facility’s policy and procedure (P&P) titled “Central Venous Line/Peripherally Inserted Central Catheter: Assisting, Insertion, Care and Removal Policy,” the “P&P” indicated: Scope: Hospital Wide Purpose: 1. To provide guidelines for safe insertion and care of Central Venous Catheter (CVC). 2. To prevent Central Line Associated Bloodstream Infections (CLABSI). Policy: CVC site dressing is checked daily and may be changed every seven (7) days and whatever the dressing becomes soiled, moist, or loose. B. CVC AND PICC SITE CARE: 1. Dressing should be changed every seven (7) days using aseptic technique and transparent, semi-permeable dressing to cover the catheter site or when the dressing becomes damp, loose or visibly soiled. ...3. If the patient is diaphoretic, or if the site is bleeding or oozing, apply 2x2 non adherent gauze over the catheter site, cover with 2x2 sterile gauze then cover with the transparent semipermeable dressing.” During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy - Administration Policy,” dated April 2016, the “P&P” indicated: Scope: Hospital Wide Policy: 4. Central line dressing should be changed weekly and as needed. 4.b. During a review of Patient 45’s “Face Sheet,” dated 8/19/2025, the Face Sheet indicated Patient 45 was admitted to the facility on 8/19/2025 at 12:34 p.m. During a review of Patient 45’s “History and Physical (H&P),” dated 8/19/2025, the “H&P” indicated the following: Patient 45 had chief complaint of bilateral (both) lower extremities edema (swelling in the feet, ankles, and lower legs) and seizure disorder (abnormal electrical activity in your brain). During a review of Patient 45’s PICC Insertion Documentation, dated 8/20/2025, the “PICC Insertion Documentation” indicated the following: Patient 45 had a PICC line inserted to the right upper arm. During a concurrent observation and interview on 9/09/2025 at 10:35 a.m. with Charge Nurse (CN 2) and Registered Nurse (RN 1), in Patient 45’s room, Patient 45 had a PICC line to the right upper arm with the following observation: No securement device used to hold the PICC line in place at insertion site, and was unable to visualize external measurement and marking of PICC line because the transparent dressing was incorrectly placed and did not show the external measurements/marking of the PICC line.. RN 1 stated the following: She (RN 1) did not assess the PICC line dressing today (9/09/2025) and did not know if RN 1 should change the dressing on the PICC line. CN 2 stated the following: Patient 45’s dressing should be changed. Confirmed no device to secure PICC line was used and unable to see the external measurement of the PICC line because the dressing was incorrectly placed. CN 2 said there was a risk for PICC line to migrate if not using a securement device. CN 2 will change the dressing. During an interview on 9/12/2025 at 10:58 a.m. with the Intensive Care Unit Director (ICUD 1), ICUD 1 stated the following: Confirmed RN 1 did not provide proper PICC line maintenance care for Patient 45. RN 1 did not use a securement device, the PICC can migrate when not properly secured. During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Line/Peripherally Inserted Central Catheter: Assisting, Insertion, Care and Removal Policy,” the “P&P” indicated: Scope: Hospital Wide Purpose: 1. To provide guidelines for safe insertion and care of Central Venous Catheter (CVC). 2. To prevent Central Line Associated Bloodstream Infections (CLABSI). Policy: CVC site dressing is checked daily and may be changed every seven (7) days and whatever the dressing becomes soiled, moist, or loose. B. CVC AND PICC SITE CARE: 1. Dressing should be changed every seven (7) days using aseptic technique and transparent, semi-permeable dressing to cover the catheter site or when the dressing becomes damp, loose or visibly soiled. 3. If the patient is diaphoretic, or if the site is bleeding or oozing, apply 2x2 non adherent gauze over the catheter site, cover with 2x2 sterile gauze then cover with the transparent semipermeable dressing.” During a review of the facility’s policy and procedure (P&P) titled “IV Therapy - Administration Policy,” dated April 2016, the “P&P” indicated: Scope: Hospital Wide Policy: 4. Central line dressing should be changed weekly and as needed.”

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 46238 Based on interview, and record review, the facility failed to notify and involve one of 30 sampled patient’s (Patient 1) patient representative (RP), who was Patient 1’s Durable Power of Attorney (DPOA, a legal document that grants another person the authority to make decisions on behalf of the patient should the patient becomes incapacitated [person’s inability to manage his/her personal care, property or finances]), with regards to Patient 1’s inpatient treatment course as well as provide clear discharge instructions to Patient 1’s RP prior to Patient 1’s discharge. This deficient practice resulted in the violation of Patient 1’s rights by not notifying Patient 1’s appointed representative (RP) about Patient 1’s treatment such as the use of restraints (devices that limit a patient’s movement) on Patient 1 and not involving Patient 1’s representative in discharge planning (the process of identifying and preparing for a patient’s anticipated healthcare needs after they leave the hospital) before Patient 1’s discharge to home. This deficient practice also had the potential to compromise Patient 1’s treatment recovery after discharge, due to lack of communication regarding post hospital care instructions such as wound care treatment. Findings: During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/19/2023, the H&P indicated, Patient 1 was admitted for urinary tract infection (infection of any part of the urinary system such as the bladder), chest pain, and pneumonia (infection of the lungs). During an interview on 12/26/2023 at 10:23 a.m. with Patient 1’s representative (RP), the RP stated, the facility did not update Patient 1’s RP of Patient 1’s course of medical treatment and restraint (devices that limit a patient’s movement) use on Patient 1 from 9/21/2023 through 9/22/2023. The RP stated, the facility did not request to provide proof of Durable Power of Attorney (DPOA, a legal document that grants another person the authority to make decisions on behalf of the patient should the patient becomes incapacitated [person’s inability to manage his/her personal care, property or finances]), after Patient 1’s RP notified the facility staff of being Patient 1’s DPOA. The RP further stated, the RP was not provided discharge instructions when Patient 1 was discharged on 9/22/2023 and the discharge documentation did not provide details of Patient 1’s admission diagnosis and treatment course during Patient 1’s admission and treatment in the facility from 9/19/2023 through 9/22/2023. During a review of Patient 1’s medical record (MR) titled, “Progress Notes Report,” dated 9/19/2023-9/23/2023, the MR indicated, on 9/19/2023, primary nurse documented information about Patient 1’s RP/DPOA and informed of Patient 1’s admission. During a concurrent interview and record review on 12/27/2023 at 1:38 p.m. with Informatics Analyst (IA, responsible for digital technology to transform data and information), Patient 1’s medical record (MR), dated 9/21/2023 through 9/22/2023 was reviewed. The MR indicated, Patient 1 was confused, agitated, and combative from 9/21/2023-9/22/2023. The MR further indicated, no documentation in Patient 1’s medical record of Patient 1’s family notification about on-going treatment plan and restraint application from 9/21/23 through 9/22/2023. The IA stated, the primary nurse did not make any documentation in Patient 1’s medical record about updating Patient 1’s RP/DPOA regarding Patient 1’s treatment plan and restraint application. During a concurrent interview and record review on 12/27/2023 at 1:38 p.m. with the director of nursing (DON), Patient 1’s medical record (MR) titled, “Discharge Instructions,” dated 09/22/2023, was reviewed. The Discharge Instructions indicated, home medications were not marked to be continued or changed. The MR further indicated, discharge instructions were provided on “Chest Pain” and “Wound Care” with no documentation of instructions provided. The MR further indicated, the discharge instructions were provided to Patient 1’s caregiver, but there was no signature or full name placed in the “Received by” space allocated for the receiver to sign on the discharge instructions. The MR indicated, the primary nurse did not document contacting the Patient 1’s RP to provide discharge instructions on the day of Patient 1’s discharge on 9/22/2023. The DON stated, based on the documentation reviewed, the discharge instructions were not clear, and the primary nurse did not provide clear discharge instructions to Patient 1’s caregiver about the wound care and the treatment course of Patient 1’s admission stay from 09/19/2023 to 09/22/2023. During an interview on 12/28/2023 at 12:44 p.m. with the social worker (SW 1), the SW 1 stated, the SW 1 recalled speaking with Patient 1’s RP on 9/9/20/2023, and the RP informed the SW, that the RP held Patient 1’s DPOA. The SW 1 stated that Patient 1’s RP did not provide physical proof of being Patient 1’s POA. The SW 1 stated, the SW 1 documented in SW 1’assessment, that Patient 1 did not have DPOA representative. The SW 1 further stated, the SW 1 did not recall if the SW 1 provided Patient 1’s RP with any means (fax number or email) to provide proof of DPOA to the facility for Patient 1. During an interview on 9/28/2023 at 1:14 p.m., with SW 1, the SW 1 stated, the facility does not have a clear process as to who should update information about patients’ representatives, DPOA’s and or conservatorship (when a judge appoints another person to act or make decisions for a person who needs help) holders. The SW 1 stated, the responsibility of validating the patient’s next of kin information and/or verification of legal representative status is not solely the social worker’s responsibility, and all staff is responsible. During an interview on 12/28/2023 at 2:32 p.m. with Patient Access Manager (PAM), the PAM stated, updating a patient’s personal information, including but not limited to, patient’s legal status, next of kin, and/or an emergency contact information is the responsibility of the admitting staff. The PAM further stated, patient’s legal status and validating information such as DPOA is the responsibility of the facility’s social worker. The PAM further stated, the facility does not have a step-by-step procedure on how to validate patient representative information and who should be held accountable for this process. During an interview on 12/29/2023 at 9:58 a.m. with the Director of Medical Surgical and Telemetry unit (DMS), the DMS stated, if a patient is unable to make medical decisions for themselves, the facility should be aware of patient’s representative choices, especially if a patient has a representative with a Durable Power of Attorney. The DMS further said, the facility should notify DPOA of patient treatment and discharge planning, and provide clear discharge instructions to DPOA, because discharge instructions are important for management of their health condition after hospital discharge. During a review of the facility’s policy and procedure (P&P) titled, “Consent for Treatment: determination of Patient’s Legally Authorized Representative,” dated 12/2023, the P&P stated, “The determination of who has the legal power of authority to consent to medical treatment for a patient is based on the patient’s legal status and on the physical condition of the patient. If patient lacks capacity, someone else must consent to the treatment on the patient’s behalf and the person authorizing the treatment should be verified.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48186 Based on observation, interview and record review, the facility failed to: 1. Provide language services necessary in the care of one of 30 sampled patients (Patient 12) in order to explain planned treatment and to verify understanding of consent for a surgical procedure in accordance with the facility’s policy and procedure regarding the use of interpreter services (verbal services bridging the language gap between a patient and a provider, which is essential to provide the best possible quality of care). This deficient practice had the potential in providing patients with deficient care and causing patient harm due to ineffective communication between healthcare provider and the patient. 2. Ensure a full oxygen cylinder (stores oxygen under pressure and is used for patients with difficulty breathing) was checked, placed, and maintained on a crash cart (The intent of a crash cart is to ensure that the correct emergency equipment, medications, and supplies are readily available to manage an emergency situation) for one of two sampled oxygen cylinders in accordance with the facility’s policy and procedure regarding oxygen cylinders in a crash cart. This deficient practice had the potential to compromise patient health and safety in an emergent patient care situation due to the lack of available full oxygen cylinder that delivers needed oxygen to a patient. 3. Ensure Physician orders (a physician’s direction for treatment) regarding tube feeding (a flexible tube is inserted through the nose and goes directly to the stomach to deliver nutrition when someone cannot eat through the mouth) and restraints (a mechanical device or equipment that immobilizes or reduces the ability of a person to move freely) use were followed for three of six sampled patients (Patients 16, 18 and 25) in accordance with the facility’s policies and procedures regarding tube feeding and restraints use when: 3a. Patient 16’s tube feeding was not administered as a continuous feeding. 3b. Patient 18’s tube feeding was not increased every 6 hours to reach the goal rate. 3c. Patient 25 did not have a Physician order for the use of bilateral (affecting both sided) soft wrist restraints (a mechanical device or equipment that immobilizes or reduces the ability of a person to move freely). These deficient practices had the potential to compromise Patient 16 and Patient 18’s nutritional status resulting in dehydration (body does not have as much water and fluids as it needs), malnutrition (lack of proper nutrition, caused by not having enough to eat), weight loss, and fluid and electrolyte imbalance (abnormal water and minerals in the body) leading to organ dysfunction or failure. The deficient practice also had the potential to cause harm such as skin laceration to Patient 25 due to lack of proper interventions to monitor restraints use. 4. Provide written discharge instructions (educational material given to patient/caregiver addressing the patient’s activity level after discharge “exiting” from the hospital) for one of 15 sampled patients (Patient 16) in accordance with the facility’s policy and procedures regarding discharge instructions. This deficient practice had the potential to affect the medical care needed after discharge, due to a lack of knowledge of the patient/caregiver/patient representative regarding post hospital care, leading to healthcare complications that can result in readmission to the hospital, serious harm or death of the patient. 5. Provide two employee witnesses for verification of consent obtained by phone from a patient’s representative for one of 15 sampled patients (Patient 18) during the admission process in accordance with the facility’s policy and procedure regarding the consent process. This deficient practice had the potential for Patient 18’s family representative not to fully understand the scope of services provided by the facility and also had the potential for an important information not to be relayed to the patient’s representative which may affect the patient’s treatment plan. Findings: 1. During a review of Patient 12’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/26/2023, the H&P indicated, Patient 12 was admitted to the facility on 12/25/2023 for evaluation of abdominal pain and was diagnosed with acute pancreatitis (a condition where the pancreas [an organ that helps with digestion and regulation of the body’s blood sugar] becomes inflamed [swollen] over a short period of time). During a review of Patient 12’s medical record (MR) titled, “Admission Assessment Report,” dated 12/25/2023, the MR indicated, Patient 12’s preferred language (spoken and written) was Spanish. During further review of Patient 12’s MR titled,” Admission Assessment Report,” dated 12/25/2023, the MR indicated, Patient 12’s primary nurse documented using a certified nursing assistant (CNA) as a translator when performing Patient 12’s admission assessment on 12/25/2023. During a concurrent interview and record review, on 12/29/2023 at 10:14 a.m., with Informatics Analyst (IA, responsible for digital technology to transform data and information) and the Chief Nursing Officer (CNO), Patient 12’s medical record (MR) titled “Progress Note Report,” dated 12/26/2023, was reviewed. The Progress Note Report indicated, Patient 12’s primary nurse documented using a CNA as a translator to explain physician’s orders and reasons for cancelling Patient 12’s surgery on 12/26/2023 at 6:00 p.m. The IA stated, the facility does not have medical interpreter certified staff in any language, and nursing staff must use videoconferencing technology that offers the delivery of interpreter services (verbal services bridging the language gap between a patient and a provider, which is essential to provide the best possible quality of care), as per facility’s policy and procedures. During a concurrent interview and record review on 12/29/2023 at 10:30 a.m. with the Chief Nursing Officer (CNO), Patient 12’s consent for a procedure titled, “Endoscopic Retrograde Cholangiopancreatography (a procedure to diagnose problems with the liver, gallbladder [organ that stores bile, a fluid produced by the liver to break down fatty foods], bile ducts [tubes that connects the liver and the gallbladder to the small bowel], and pancreas) with possible Splenectomy (surgical procedure to remove a damaged spleen [an organ that filters blood and protects the body from infection]), stone extraction, and stent (a small plastic tube to keep an obstructed bile duct open) placement,” dated 12/26/2023 was reviewed. The consent indicated, no Spanish interpreter information was documented when verified consent was obtained on 12/26/2023. The CNO stated, a nurse, verifying the obtained consent for Patient 12 on 12/26/2023 did not document using translator services as per facility’s policy. During an interview on 12/29/2023, at 10:14 a.m. with the Director of Medical Surgical and Telemetry unit (DMS), the DMS stated, nurses are expected to use interpreter services through videoconferencing technology, offered by the facility. The DMS stated, staff must not use certified nursing assistants to translate medical terminology because CNAs do not have the qualifications to serve as language interpreters and may not fully understand and correctly translate health sensitive information to patients. During a review of the facility’s policy and procedure (P&P) titled, “Communication: Patients with Limited English Proficiency,” dated 10/2023, the P&P indicated, “Day-to-day conversation or decision not related to treatment or medications may be interpreted by family members, friends, or staff members. Decisions or discussions related to treatment or medications may be interpreted by staff members who have validated competency in medical terminology. Language assistance will be provided using qualified translation services and technology and/or telephonic interpretation services.” During a review of the facility’s policy and procedure (P&P) titled, “Communication: Patients with Limited English Proficiency,” dated 10/2023, the P&P indicated, “Instances of translation must be documented in the patient’s medical record to include translator services or translation number as provided by the vendor used for the translation.” 2. During an observation on 12/26/2023 at 2:08 p.m., at the medical surgical floor (a nursing specialty unit and hospital floor where a variety of patients are cared for, including patients who just had surgery and are recovering), crash cart #3 (a cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate [to revive] a patient experiencing cardiac arrest [heart attack]) was observed. The Crash Cart #3 contained an oxygen cylinder (stores oxygen under pressure and is used for patients with difficulty breathing), and showing the amount of pressure of oxygen in the cylinder was below 1000 psi (pounds per square inch, an oxygen measuring unit) indicating there was only 12 minutes of oxygen to run if oxygen was administered at 10 Liters/minute (measuring unit). During an interview on 12/26/2023 at 14:08 p.m. with the Director of Nursing (DON), the DON stated, crash cart oxygen cylinders should be full and the reading on the regulator should be above 1000 PSI as per facility’s policy and procedures. The DON stated, the oxygen cylinder on crash cart #3 must be replaced with a full oxygen cylinder because if there is an emergency on the floor, patients may have negative outcomes and/or delay of care should they need oxygen, and the oxygen cylinder is not full. During a concurrent interview and record review on 12/26/2023 at 14:20 p.m. with charge nurse (RN 3) 3, crash cart #3 checklist, dated 12/26/2023, was reviewed. The crash cart #3 checklist indicated, on 12/26/2023 at 7:00 a.m., a checkmark (indicating crash cart #3 was checked and maintained to ensure the correct emergency equipment and supplies are readily available to manage the emergency) was placed next to “Oxygen tank at least 1000 PSI” column. The RN 3 stated, the documentation indicated that the crash cart #3 was inspected and oxygen amount in the oxygen cylinder was verified. However, the RN 3 further checked the oxygen pressure on the regulator and stated there was less than 1000 PSI of available oxygen in the cylinder and the tank had to be replaced as per facility’s policy. During a review of the facility’s policy and procedure (P&P) titled, “Crash Cart Equipment and Medications,” dated 12/2023, the P&P indicated, “Emergency carts are to be checked at a minimum of once each calendar day by an assigned licensed nurse for the presence of including but not limited to, oxygen cylinder present and at least half full (more than 1000 PSI). During a review of the facility’s policy and procedure (P&P) titled, “Compressed Gases Cylinder Management Policy,” dated 7/2023, the P&P indicated, “Only full oxygen cylinders (more than 2000 PSI) should be used for emergent patient care situations. Only full oxygen cylinders should be placed on crash carts.” 3a. During a review of Patient 16’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 12/12/2023, the face Sheet indicated Patient 16 was admitted to the facility on 12/12/2023 at 5:44 p.m. with diagnoses of urinary tract infection (UTI, infection of the bladder and/or other parts of the urinary system, where urine is produced and filtered), sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria), and tachycardia (increased heart rate). During a review of Patient 16’s initial nutrition assessment, dated 12/13/2023 at 2:19 p.m., ithe initial nutrition assessment indicated recommendations by Registered Dietician (RD) to adjust enteral nutrition (EN, the delivery of nutrients beyond the esophagus by feeding tubes) regimen to Jevity 1.5 (a type of tube feeding formula) at 50 milliliters per hour (mL/h, a unit of measurement) to provide 1800 calories (kcals), 77 grams (g) protein. During a review of Patient 16’s physician order, dated 12/13/2023 at 10:30 a.m., the physician’s order indicated an order for tube feeding, Jevity 1.5 continuous at 50 mL/h. The order further indicated this order was active until discontinued 12/26/2023 at 6:50 p.m. During a review of Patient 16’s daily gastrointestinal (GI, stomach and intestines) assessment, dated 12/13/2023 at 4 p.m., indicated the patient was “seen by nutrition evaluated gastrostomy tube (g-tube, a tube surgically placed through the abdomen into the stomach for feeding). Ok to go up to 50 mL/h.” During a review of Patient 16’s intake and output (I&O), dated 12/13/2023 at 7:00 p.m., the I&O indicated, Patient 16’s tube feeding was initiated at 50 mL/h. During an observation 12/26/2023 at 1:17 p.m., Patient 16’s g-tube was connected to the tube feeding tubing (a device used to transfer medications or fluids to someone), with the tube feeding pump not running. Observed the bottle “Jevity 1.5 CAL (1.5 calories per ml)” hanging from the IV pole (a place to hang medications or fluids) was empty with the tubing closest to the bottle dry and tubing closest to the patient with residual formula. The label on the bottle stated it was hung “12/25/2023 at 12 p.m.” During a concurrent observation and interview on 12/26/2023 at 1:25 p.m. with Registered Nurse 2 (RN 2), RN 2 verified Patient 16’s tube feeding pump was off. RN 2 stated the tube feeding ended around 9 a.m., and the feeding was not restarted. RN 2 stated that she forgot to call to request a new bottle from dietary. RN 2 stated each tube feeding formula bottle should run continuous at 50mL/h for a total of 20 hours and each bottle contains 1 liter (L) of formula. RN 2 verified the Physician’s order in Patient 16’s chart as Jevity 1.5 CAL at 50 mL/h, continuous. RN 2 confirmed the tube feeding is not running per the Physician’s order, and stated if the orders are not followed the g-tube can get clogged, the patient can miss calories, become dehydrated, and lose weight. During a record review of Patient 16’s daily tube feeding assessment, dated 12/26/2023 at 2:00 p.m., the daily tube feeding assessment indicated, “spike set and pump tubing were changed once a new formula bag was hung (due 7:00 am- 7:00 p.m. shift and 7:00 p.m.- 7:00 a.m. shift).” During a review of the facility’s policy and procedures (P&P) titled, “Feeding by Nasoenteric (tube passed from the nose into the stomach), Gastrostomy (a surgical opening into the stomach from the abdominal wall where a feeding tube is inserted to bring nutrition directly to the stomach), or Jejunostomy (a surgical procedure wherein a plastic tube is inserted through the abdominal skin into the small intestine to deliver nutrition) Tube,” dated 10/2023, the P&P indicated: “Policy: Initiation and discontinuation of enteral tube feeding requires a Physician/Nurse Practitioner (NP) order. RNs and LVNs may administer enteral feedings. Continuous tube feeding will be regulated by an enteral pump ... Procedure: A. Non-air dependent closed tube feeding system ... 12. Turn on pump ... 14. Set infusion rate per hour per physician order and start infusion.” 3b. During a review of Patient 18’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 12/23/2023, the face Sheet indicated, Patient 18 was admitted to the facility on 12/23/2023 at 1:55 p.m. with diagnoses of pneumonia (lung inflammation caused by bacterial or viral infection) and non-ST-elevation (NSTEMI, a type of heart attack that usually happens when your heart’s need for oxygen can’t be met). During a review of Patient 18’s daily gastrointestinal (GI, stomach and intestines) assessment, dated 12/25/2023 at 8 p.m., the daily gastrointestinal assessment indicated, Patient 18 had a gastrostomy (g-tube, a tube surgically placed through the abdomen into the stomach for feeding). During a review of Patient 18’s Physician order, dated 12/22/2023 at 5:12 a.m., the Physician order indicated an order for nothing by mouth (NPO, a period of time in which someone may not eat or drink). During a review of Patient 18’s Physician order, dated 12/25/2023 at 3:18 p.m., the Physician order indicated an order for tube feeding (a tube that goes directly to the stomach or small intestine), Glucerna 1.2 (a type of tube feeding formula), increase 10 milliliters (mL, a unit of measurement) q (every) 6 hours as tolerated with a goal of 60 milliliters per hour (mL/h). During a review of Patient 18’s intake and output (I&O, a document that records fluids in and out of a person’s body), the I&O indicated Patient 18’s Glucerna tube feeding was initiated at 10 mL/h on 12/25/2023 at 8 p.m., then increased to 20 mL/h on 12/26/2023 at 8:00 p.m., 30 mL/h on 12/26/2023 at 4:00 p.m., and 40 mL/h on 12/27/2023 at 12:00 a.m. During a concurrent interview and record review of Patient 18’s medical record on 12/27/2023 at 2:05 p.m. with the Clinical Informatics Nurse (CIN), the medical record indicated on Patient 18’s physician orders that Patient 18 was previously NPO, and tube feedings were ordered on 12/25/2023 at 3:18 p.m. CIN verified the Physician order for tube feedings to increase 10 ml/h every 6 hours a tolerated. A review of Patient 18’s daily tube feeding assessment indicated tube feeding on 12/25/2023 at 8 p.m. was at 20 mL/h. CIN confirmed that Patient 18’s tube feedings were not increased per Physician’s orders. Patient 18’s daily tube feeding assessment further indicated, Patient’s 18’s tube feedings were at 20 mL/h on 12/26/2023 at 8:00 a.m., and at 30 mL/h on 12/26/2023 at 8 p.m. CIN verified Patient 18’s gastric residuals were not checked every 4 hours per policy for continuous feedings, with one documented residual (amount of liquid drained from the stomach following administration of enteal feed) of less than 100 milliliters (mL) from 12/25/2023 8:00 p.m. and on 12/26/2023 8 p.m. During an interview on 12/29/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), DMS stated that tube feedings should be followed and titrated in accordance with the doctor’s orders. DMS stated that if the doctor orders for tube feedings are not followed, the patient will not get the proper nutrition needed. During a review of the facility’s policy and procedures (P&P) titled, “Feeding by Nasoenteric (tube passed from the nose into the stomach), Gastrostomy (a surgical opening into the stomach from the abdominal wall where a feeding tube is inserted to bring nutrition directly to the stomach), or Jejunostomy (a surgical procedure wherein a plastic tube is inserted through the abdominal skin into the small intestine to deliver nutrition) Tube,” dated 10/2023, the P&P indicated: “Policy: Initiation and discontinuation of enteral tube feeding requires a Physician/Nurse Practitioner (NP) order. RNs and LVNs may administer enteral feedings. Continuous tube feeding will be regulated by an enteral pump ... Patient Care Policies: C. Patient is checked for gastric feeding residual every (4) hours until goal rate is achieved, then checked every 8 hours and as needed (PRN) .... Procedure: A. Non-air dependent closed tube feeding system ... 14. Set infusion rate per hour per physician order...” 3c. During a review of Patient 25’s Face Sheet (a document that gives a patient’s information at a quick glance), the Face Sheet indicated Patient 25 was admitted to the facility on 12/26/2023 at 2:46 a.m. with diagnoses of sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria), right sided pneumonia (lung inflammation caused by bacterial or viral infection), hyperkalemia (a higher than normal level of potassium in the bloodstream), and hypernatremia (a higher than normal level of sodium in the bloodstream). During a concurrent interview and record review on 12/28/2023 at 11:35 a.m. with the Clinical Informatics Nurse (CIN), Patient 25’s Physician orders was reviewed. The Physician orders indicated an order for soft wrist restraints, dated 12/26/2023 at 11:13 p.m. and on 12/28/2023 at 10:25 a.m. The CIN verified there was no order for restraints on 12/27/2023. Patient 25’s restraint nursing assessment indicated bilateral (affecting both sides) soft wrist restraints were applied 12/27/2023 at 12:00 a.m. and continued through 12/28/2023. CIN verified there was no notification to the family when initiating the restraints and for ongoing bilateral soft-wrist restraint use. CIN stated that the restraint policy indicated there must be a new order placed every calendar day for restraint use and it can be at any time during the day. During a review of Patient 25’s Care Plan (form that summarizes a person’s health conditions, specific care needs, and current treatments), initiated 12/27/2023 at 2:02 a.m., the Care Plan indicated, “patient will not pull out tracheostomy (trach, a surgically created hole “stoma” in your windpipe (trachea) that provides an alternative airway for breathing)/tubes: apply bilateral soft wrist restraints as ordered, apply restraints as ordered, educate family on how they can participate in the patient’ care, notify family that patient was placed in restraints ...” During an interview on 12/28/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), DMS stated that patients should have an order for restraints and the restraint order should be renewed every calendar day by a physician. DMS stated that family should be notified immediately or as soon as possible when a patient is placed in restraints. DMS stated if the family is not notified of restraints, they may not know what is going on with their family member and it may be upsetting to the family. During a review of the facility’s policy and procedures (P&P) titled, “Use of Restraint or Seclusion,” dated 10/2023, the P&P indicated: “ ...Notification of the Patient’s Attending Physician: The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. The attending physician is the physician who is responsible for the management and care of the patient. Orders for Restraint for Safety / Non-Violent/ Non-Self Destructive Behavior: Orders obtained in accordance with this policy to address a patient’s medical care-related needs (safety) that are evidenced by non-violent or non-destructive behavior (non-behavioral restraint) are considered in full force and effect for up to 24 hours or 1 calendar day - which includes the day the order was obtained ...” 4. During a review of Patient 16’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 12/12/2023, the Face Sheet indicated, Patient 16 was admitted to the facility on 12/12/2023 at 5:44 p.m. with diagnoses of urinary tract infection (UTI, infection of the bladder and/or other parts of the urinary system, where urine is produced and filtered), sepsis (a life-threatening complication from infection, causing the body to have a severe inflammatory response to bacteria), and tachycardia (increased heart rate). During a concurrent interview and closed record review on 12/27/2023 at 10:40 a.m. with the Clinical Informatics Nurse (CIN), the CIN verified that Patient 16 did not have written discharge instructions (educational material given to patient/caregiver addressing the patient’s activity level after discharge “exiting” from the hospital) in the electronic medical chart (collective documentation of an individual patient’s important clinical data and medical history over time). CIN stated she checked Patient 16’s physical medical chart for a signed written discharge instructions and was unable to find the signed discharge instructions. CIN stated that all discharged patients should have a signed copy in the patient chart by the patient and nurse, per policy. During an interview on 12/28/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), the DMS stated that for discharge instructions, the patient/family and family needs to sign off. DMS stated instructions and signatures are scanned and put into the electronic chart. DMS said that if discharge instructions are not provided, the patient or family may not follow instructions, because they will not know what to do. DMS stated discharge instructions are patient specific and it is important for the patient to have clear discharge instructions so the patient/family will know what to do per doctor’s orders (a physician’s direction for treatment). During a review of the facility’s policy and procedures (P&P) titled, “Discharge- Process,” dated 12/2023, the P&P indicated: “1. Policy: ...2. Discharge/transfer summary will be documented by the Registered Nurse (RN) or Licensed Vocational Nurse (LVN) and placed in a patient’s record. 2. Procedure: ...5. Complete discharge instructions 6. Educate patient/significant other regarding discharge instructions; take home prescription copy, and the Food and Drug interaction. 7. Obtain patient/significant other with copy instructions ... 9. Place a copy in the chart ...” 5. During a review of Patient 18’s Face Sheet (a document that gives a patient’s information at a quick glance), dated 12/23/2023, the Face Sheet indicated, Patient 18 was admitted to the facility on 12/23/2023 at 1:55 p.m. with diagnoses of pneumonia (lung inflammation caused by bacterial or viral infection) and non-ST-elevation (NSTEMI, a type of heart attack that usually happens when your heart’s need for oxygen can’t be met). During a review of Patient 18’s Conditions of Admission (an agreement between the patient/family representative and facility, signed during admission, for treatment and services provided by the facility to the patient), dated 12/26/2023, the COA indicated, Patient 18’s family representative, was verbally consented by one facility representative. Patient 18’s family representative provided verbal consent for the following services provided by the facility, as listed on the Conditions of Admission: 1. Consent to Medical and Surgical Procedures 2. Photography 3. Prescription history 4. Nursing Care 5. Legal Relationship 6. Personal Belongings 7. Financial Agreement 8. Assignment of All Rights 9. Health Plan Contracts 10. Maternity (pregnant) Patients 11. Health Information Exchange 12. Telephone Consumer Protection Act (TCPA) 13. The Cellular Telecommunications Industry Association Guidelines (CTIA) 14. Advanced Directives (a written statement of a person’s wishes regarding medical treatment) Patient 18’s Conditions of Admission further indicated “I certify I have read the forgoing and my signature below represents that I am the patient, patient’s legal representative, or am otherwise authorized by the patient to sign the above and accept its terms on his/her behalf.” Patient 18’s Conditions of Admission form was signed by one facility staff and Patient 18’s family representative, indicating verbal consent by phone on 12/26/2023 at 1:06 p.m. During a concurrent interview and record review on 12/27/2023 at 2:05 p.m. with the Director of Nursing (DON), DON verified the Conditions of Admissions was signed by one staff member and should have been witnessed by two staff when obtaining verbal telephone consent. During an interview on 12/29/2023 at 2:55 p.m. with the Medical Surgical Director (DMS), the DMS stated that when obtaining consent by telephone (verbal consent), it is important to make sure there are two staff witnesses otherwise the patient or family may be signing something they do not fully understand. During a review of the facility’s policy and procedures (P&P) titled, “Consent,” dated 7/2022, the P&P indicated: “Purpose: To clearly define a patient’s right to consent to treatment and an employee’s from this facility, role in the consent process, as well as to clarify the consent process. Procedure: A competent, adult patient has the fundamental right to participate in his/her own medical care, to exercise control over his/her own body, and to determine whether he/she will submit to prescribed medical care. Obtaining informed consent is an active process in which each participant in the treatment of a patient and anesthetist, physician and surgeon provides all material information to enable the patient to make an informed decision regarding any proposed procedures and/or recommended care... The basic agreement between the patient and this facility is the Condition of Admission. This agreement when signed by the patient or legal representative upon admission, permits the Hospital and attending physician to proceed with the care of the patient... Obtaining and Verifying Signed Permit: 1. Obtaining/Witnessing Consent: The Admitting Office has the primary responsibility for obtaining signatures on the Hospital Admissions Agreement form at the time the patient is admitted. Employees of the facility may sign Hospital forms while acting in the capacity of a witness. All witnesses must be 18 years of age or older, and must be present when the form is signed. The witness must indicate in the designated space on the form that he/she witnessed the actual signing, a. If a patient is incompetent and the patient’s legal representative is unable to come to the Hospital to sign consent(s) prior to treatment, consent over the phone or by wire (telegram or facsimile) is acceptable, b. Written record of both types of consent should be attached to the patient’s permanent medical record ... 3. Consent by Telephone, Telegraph, or Facsimile: Consent for medical or surgical treatment may be obtained via telephone, telegraph, or facsimile only If the person has legal capacity to consent for the patient and is not physically available. If consent is obtained using the above-mentioned media, the physician must provide the decision-maker with the information he/she would otherwise disclose. Hospital personnel must verify that the patient’s decision-maker and physician have discussed the patient’s condition and recommended treatment, and the patient’s decision-maker must be informed that another employee will be listening to the decisions. Both employees are to sign and date the verification of consent ...””